New Patient Intake Forms
This information is required by your provider to conduct your initial assessment. Please complete it as thoroughly as possible. If any section does not apply to your reason for seeking an appointment, feel free to skip that section. Please answer honestly; this information is confidential. If you have any questions while completing these forms, please call our office at 612-436-0295.
Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
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Please select a year
2025
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Year
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Briefly explain your reason for establishing care:
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Adult Symptom Screener
Summary of Symptom Screening
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
The following questions relate to your experiences of the last 6 months:
In the past 6 months, did you ever have a spell or an attack when all the sudden you felt frightened, anxious, or very uneasy?
*
Yes
No
In the past 6 months, did you ever have a spell or an attack where for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath?
*
Yes
No
Did any of these spells or attacks ever happen in a situation when you were not in danger or not the center of attention?
*
Yes
No
Please respond to the degree that the following problems have bothered you during the past week.
*
Not at all
A little bit
Somewhat
Very much
Extremely
Fear of embarrassment causes me to avoid doing things or speaking to people
I avoid activities in which I am the center of attention
Being embarrassed or looking stupid are among my worst fears
Have you experienced any of the following traumatic events: natural disaster (e.g., flood, hurricane, tornado, earthquake), fire, explosion, or industrial accident; transportation accident (e.g., car accident, plane crash); physical assault (e.g., being attacked, beaten up); sexual assault (e.g., rape, attempted rape, made to perform any type of sexual act through force or threat of harm); captivity or exposure to a war-zone; life-threatening illness or injury; sudden, unexpected death of or injury to someone close to you; or serious injury, harm, or death to someone else that you witnessed or caused?
*
Yes
No
Has this event caused any significant problems or symptoms that lasted for more than a month?
*
Yes
No
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Has there ever been a period of time when you were not your usual self and...
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
*
Yes
No
...you were so irritable that you shouted at people or started fights or arguments?
*
Yes
No
...you felt much more self-confident than usual?
*
Yes
No
...you got much less sleep than usual and found you didn't really miss it?
*
Yes
No
...you were much more talkative or spoke much faster than usual?
*
Yes
No
...thoughts raced through your head or you couldn't slow your mind down?
*
Yes
No
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
*
Yes
No
...you had much more energy than usual?
*
Yes
No
...you were much more active or did many more things than usual?
*
Yes
No
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
*
Yes
No
...you were much more interested in sex than usual?
*
Yes
No
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
*
Yes
No
...spending money got you or your family in trouble?
*
Yes
No
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The following questions relate to your eating habits:
When you eat, do you make yourself sick because you feel uncomfortably full?
*
Yes
No
Do you ever worry that you have lost control over how much you eat?
*
Yes
No
Have you recently lost more than 14 pounds in a 3 month period?
*
Yes
No
Do you believe yourself to be fat when others say you are too thin?
*
Yes
No
Would you say that food dominates your life?
*
Yes
No
Have you ever been bothered by having to perform some ritual or act over and over that does not make sense?
*
Yes
No
The following questions relate to your alcohol and substance use:
How often do you have a drink of alcohol?
*
Never (Skip the next 2 questions)
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week
How many drinks containing alcohol do you have on a typical day when you are drinking?
*
1 to 2
3 to 4
6 to 8
7 to 8
10 or more
How often do you have six or more drinks on one occasion?
*
Never
Less than montly
Monthly
Weekly
Daily or almost daily
In the past year have you used an illegal drug or used a prescription medication for non-medical reasons?
*
Yes
No
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Please answer the questions below, rating yourself on each of the criteria shown using the scale provided. As you answer each question, select the option that best describes how you have felt and conducted yourself over the past 6 months.
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
*
Never
Rarely
Sometimes
Often
Very often
How often do you have difficulty getting things in order when you have to do a task that requires organization?
*
Never
Rarely
Sometimes
Often
Very often
How often do you have problems remembering appointments or obligations?
*
Never
Rarely
Sometimes
Often
Very often
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
*
Never
Rarely
Sometimes
Often
Very often
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
*
Never
Rarely
Sometimes
Often
Very often
How often do you feel overly active and compelled to do things, like you were driven by a motor?
*
Never
Rarely
Sometimes
Often
Very often
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The questions listed below relate to your thoughts and feelings. If the way you have been in recent weeks or months differs from the way you usually are, please answer based on when you were your usual self.
Do you find that most people will take advantage of you if you let them know too much about you?
*
Yes
No
Do you generally feel nervous or anxious around people?
*
Yes
No
Do you avoid situations where you have to meet new people?
*
Yes
No
Do you avoid getting to know people because you're worried that they may not like you?
*
Yes
No
Has avoidance of getting to know people due to fear of being disliked affected the number of friends that you have?
*
Yes
No
Do you keep changing the way you present yourself to people because you don't know who you really are?
*
Yes
No
Do you often feel like your beliefs change so much that you don't know what you really believe anymore?
*
Yes
No
Do you often get angry or irritated because people don't recognize your special talents or achievements as much as they should?
*
Yes
No
Have you had any unusual experiences such as hearing voices, seeing visions, or having ideas you later found out were not true?
*
Yes
No
Have you had any other experiences, such as mind reading, ESP, thoughts beng controlled by others, seeing things on TV that refer to you specifically?
*
Yes
No
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CAGE-AID Questionnaire
When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.
Have you ever felt that you ought to cut down on your drinking or drug use?
*
Yes
No
Have people annoyed you by criticizing your drinking or drug use?
*
Yes
No
Have you ever felt bad or guilty about your drinking or drug use?
*
Yes
No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
*
Yes
No
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Clinical History Form
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Stressors -- Given the list of categories below, how much stress is each currently causing you?
*
None
Mild stress
Moderate stress
Severe stress
Family
Friends
Relationships
Educational
Economic
Occupational
Housing
Legal
Health
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Substance Abuse History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Do you have a history of any recreational drug use?
*
Yes
No
If YES, please fill out the table below to the best of knowledge:
*
Age of First Use
Age of Last Use
Amount per day
Days per month
Amphetamines/Speed
Barbiturates/Downers
Opiates
Cocaine
Psychedelics (e.g. LSD, Ecstasy, bath salts)
Inhalants (e.g. glue, aerosols)
Cannabis/Marijuana/Hashish
Benzodiazepines
PCP
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Substance Abuse Treatment History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Did you receive any treatment for substance abuse?
*
Yes
No
If YES, please fill out the box below to the best of your knowledge, including treatment type (inpatient, intensive out patient, outpatient, 12-step program, other), how many episodes of treatment, age of first/last treatment, and any additional information.
*
Consequences of Substance Abuse
Have you experienced any of these consequences as a result of alcohol consumption or abuse of substances? (Please check all that apply)
*
No consequences
Felt that you needed to cut down on your drinking
Been annoyed by others criticizing your drinking
Felt guilty about drinking
Needing a drink first thing in the morning
Increased tolerance
Withdrawal (shakes, sweating, nausea, rapid heart rate)
Seizures
Blackouts
Effects on physical health
Using/consuming more than intended
Unintentional overdose
DUI
Arrests
Physical fights or assaults
Relationship conflicts
Problems with money
Job loss or problems at work/school
Other
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Inpatient Psychiatric History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Do you have a history of inpatient psychiatric treatment?
*
Yes
No
If YES, please list any past inpatient treatment history below. Start with the most recent and list each episode of treatment as a separate line. Please include which hospital/facility, voluntary/involuntary, primary reason for hospitalization, age, treatment outcome, and any additional comments.
*
Outpatient Psychiatric History
"Outpatient Psychiatric HIstory" means any mental healthcare you've received outside of a hospital, e.g., in a clinic, individual therapy, independent providers, etc.
Do you have a history of outpatient psychiatric treatment?
*
Yes
No
If YES, please list any past outpatient treatment history below. Start with the most recent and list each episode of treatment as a separate line. Please include provider's name, primary reason for seeking treatment, age of first/last treatment, and outcome.
*
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Suicide/Self-Harm History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Have you ever tried to harm or kill yourself?
*
Yes
No
Was your intent to die?
*
Yes
No
How many times in your life has this occured?
*
Elaborate below, if desired:
*
Most Severe Episode
Please describe your most severe episode including date, method, and consequences:
Most Recent Episode
Please describe your most recent episode including date, method, and consequences:
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Violence History Assessment
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Have you had any history of violent behavior?
*
Yes
No
If YES, please elaborate below:
*
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Past Medical History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Who is your primary care physician?
*
Are you taking any medications currently? (Excluding medications for psychiatric treatment)
*
Yes
No
If YES, please include these medications below:
*
Have you a history of any of the following health problems? (Please check all that apply)
*
No problems
Allergies
Anemia (low blood count)
Arthritis
Asthma
Back problems (including disk or spine)
Cancer
Cataracts
Chickenpox (as a child)
Chronic bronchitis
COPD (Emphysema)
Diabetes
Diverticulities
Fainting spells/passing out
High cholesterol
Fibromyalgia
Gall bladder disease
Gastritis or ulcers
Glaucoma
Gout
Hearing loss
Heart disease
Heart defect from birth
Heart valve problems
Hemorrhoids
Hepatitis
Hernia
HIV
Hypertension (high blood pressure)
Hypotension (low blood pressure)
Inflammatory bowel disease
Iron deficiency
Kidney disease
Kidney stones
Liver disease (other)
Lupus
Migraine headaches
Multiple sclerosis
Obesity/overweight
Parkinson's disease
Polyps
Seizures
Sexually transmitted disease (STD)
Sleep apnea
Testosterone (low)
Thyroid problems (hypothyroid/hyperthyroid)
Tuberculosis or exposure to tuberculosis
Other
Have you a history of surgery in any of the following areas? (Please check all that apply)
*
No surgical history
Back/neck
Brain
Cardiac
Ear/nose/throat
Gall blader
Hernia
Hip/knee/ankle/foot
Hysterectomy (Ovaries removed)
Hysterectomy (Ovaries retained)
Intestine
Kidney
Liver
Lung
Pancreas
Pelvis
Prostate
Sex change
Shoulder/elbow/wrist/hand
Stomach
Tonsils
Vagina
Weight Loss
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Psychiatric Medication History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Have you ever taken any medication for psychiatric treatment?
*
Yes
No
Please list the medications below:
*
Medication name
Dose
How long? (months)
End date
Therapeutic effect
Side effects
Reason for stopping?
Patient Allergies
Do you have any known allergies to medication?
*
Yes
No
If YES, please fill out your allergy information below:
Medication allergy
Allergic reaction
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Family History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Do you have any family members with a history of psychiatric illness?
*
Yes
No
If YES, please elaborate below using the following options:
Family Member: Mother, Father, Grandmother, Grandfather, Sister, Brother, Daughter, Son, Aunt, Uncle, Cousin
Psychiatric Problem(s): Depression, Panic Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Bipolar Disorder, Eating Disorder, Alcoholism, Drug Abuse, ADHD, Personality Disorder, Schizophrenia/Psychosis, Psychiatric Hospitalization, Suicide Attempt, Suicide
*
Developmental and Education History
During your pregnancy/birth, did your mother have any problems with any of the following:
*
None of these
Exposure to drugs or alcohol during pregnancy
A difficult pregnancy
Problems with delivery
Other
Did you have any complications after your birth? (e.g. premature birth, jaundice, breathing difficulties)
*
Yes
No
Did you have any delays or difficulties in reaching the following developmental milestones?
*
None of these
Walking
Talking
Toilet training
Sleeping alone
Being away from parents
Making friends
Other
Which options below best describe your childhood home atmosphere?
*
Normal
Supportive
Parental fighting
Parental violence
Financial difficulties
Frequent moving
Other
Which of the following challenges were experienced during your childhood?
*
None of these
Tantrums
Fire setting
Animal cruelty
Enuresis (bed wetting)
Encopresis (fecal incontinence)
Separation anxiety
Victim of bullying
Running away from home
Engaged in bullying
Fighting
Depression
Stealing
Death of a parent/caregiver
Property damage
Parental divorce
Which of the following best describe problems you may have had in school?
*
None of these
Fighting
School phobia
Truancy
Detentions
Suspensions
Expulsions
School refusal
Class failures
Repetition of grades
Special education
Remedial classes
Did you have additional schooling outside of the standard classroom setting? (Please check all that apply)
*
None of these
Speech classes
Tutoring
Accommodations
Other
Please select your highest level of education:
*
Less than a high school diploma
High school graduates, no college
Some college or associates degree
Bachelor's degree and higher
If you have any further comments about your developmental or educational history and wish to elaborate further, please do so in the space provided below:
*
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General Social History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Which options below best describes your social situation?
*
Supportive social network
No friends
Few friends
Distant from family of origin
Substance-use based friends
Family conflict
Other
What is your current marital status?
*
Single, never married
Married/Permanent partnership
Separated or divorce in process
Divorced
Widowed
What is the status of your intimate relationship?
*
Never been in a serious relationship
Currently in a serious relationship
Not currently in a relationship
What is the satisfaction level of your intimate relationship?
*
Very satisfied
Satisfied
Somewhat satisfied
Dissatisfied
Not applicable
What is your sexual orientation?
*
Heterosexual
Homosexual
Bisexual
Other
What is your current living situation?
*
Rent (apartment/house)
Own (house/condo)
Group home
Foster care
Homeless
Who do you currently live with? (Please check all that apply)
*
Live alone
Roommates
Partner/Spouse
Parent(s)
Siblings(s)
Children
Other
Do you currently participate in spiritual activities?
*
Yes
No
What is your current occupation status?
*
Employed full time
Employed part time
Temp / Seasonal employment
Full time student
Part time student
Homemaker
Unemployed (seeking work)
Unemployed (not seeing work)
Retired
Disability
What is your current yearly income?
*
Less than $11,000
$11,000 - $25,999
$26,000 - $75,999
$76,000 - $100,000
More than $100,000
What is your longest period of continuous employment? (Please include dates and description)
*
What is your longest period of continuous unemployment? (Please include dates and description)
*
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Menstruation and Pregnancy History
If you are filling this out on behalf of the patient, please answer from the patient's perspective.
At what age did you begin menstruation?
*
Which of these best describes your premenstrual symptoms?
*
None of these
Dysphoria
Cramps
Appetite change
Bloating
Sleep disturbance
Do you have a method of contraception? (Check all that apply)
*
No method of contraception
Intrauterine (e.g., IUD)
Hormonal (e.g., implant, injection, "the pill", patch, hormonal vaginal contraceptive ring)
Barrier (e.g., diaphragm, male/female condom, spermicide)
Fertility Awareness-based (e.g., natural family awareness)
Permanent (e.g., male/female sterilization, infertility)
Other
Have you ever been pregnant?
*
Yes
No
If YES, how many times?
*
Have you ever given birth?
*
Yes
No
If YES, how many times?
*
Have you had any miscarriages?
*
Yes
No
If YES, how many times?
*
Have you had any abortions?
*
Yes
No
If YES, how many times?
*
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Review of Systems
Please look at the list of physical symptoms below and check off any that you have experienced in the last several days. If you have NOT experienced any symptoms in an area, be sure to check "None of the above" for that area. If you are filling this out on behalf of the patient, please answer from the patient's perspective.
Constitutional
*
Chronic pain
Loss of appetite
Increase in appetite
Unexplained weight loss
Weight gain
Fatigue/Lethargy
Unexplained fever
Hot or cold spells
Night sweats
Sleeping pattern disruption
Malaise (Flu-like or vague sick feeling)
None of the above constitutional issues
Other
Eyes
*
Eye pain
Eye discharge
Eye redness
Blurred or double vision
Visual change
History of eye surgery
Sensitivity to light
Scotomas (blind spots)
Retinal hemorrhage (floaters in vision
Amaurosis fugax (feeling like a curtain is pulled over vision)
None of the above eyes issues
Other
Ears, Nose, Mouth, and Throat
*
Earache
Tinnitus (ringing in ears)
Decreased hearing or hearing loss
Frequent ear infections
Frequent nose bleeds
Sinus congestion
Runny nose/Post-nasal drip
Difficulty swallowing
Frequent sore throat
Prolonged hoarseness
Pain in jaw or tooth
Dry mouth
None of the above ear, nose, mouth, or throat issues
Other
Cardiovascular
*
Chest pain
Pacemaker
Palpitations (fast or irregular heartbeat)
Swollen feet or hands
Fainting spells
Shortness of breath with exercise
None of the above cardiovascular issues
Other
Respiratory
*
Pain with breathing
Chronic cough
Chronic shortness of breath
Chronic wheezing/Asthma
Excessive phlegm
Coughing blood
Nocturnal Dyspnea (Shortness of breath at night)
None of the above respiratory issues
Other
Musculoskeletal
*
Swelling in joints
Redness of joints
Other joint pains or stiffness
Muscle pain or cramping
Muscle weakness
Muscle stiffness
Decreased range of motion
Back pain or stiffness
History of fractures
Past injury to spine or joints
None of the above musculoskeletal issues
Gastrointestinal
*
Excessive flatulence or belching
Diarrhea
Constipation
Persistent nausea/vomiting
Abdominal pain
Heartburn
Difficulty swallowing solids or liquids
Recent loss in appetite
Sensitivity to milk products
Jaundice (yellow skin)
Change in appearance of stool
Blood in stool
Dark/Tarry stool
Loss of bowel control/soiling
None of the above gastrointestinal issues
Other
Allergic/Immunologic
*
Frequent infections
Anaphylaxic reaction
Hives
None of the above allergic or immunologic issues
Other
Endocrine
*
Severe menopausal symptoms
Cold or heat intolerance
Excessive appetite
Excessive thirst or urination
Excessive sweating
None of the above endocrine issues
Other
Hematologic/Lymphatic
*
Blood clots
Excess/easy bleeding (surgery, dental work, brushing teeth, scrapes)
History of blood transfusion
Excessive bruising
Swollen glands (neck, armpits, groin)
None of the above hematologic or lymphatic issues
Other
Genitourinary (General)
*
Loss of urine control (including bed-wetting)
Painful and/or burning urination
Blood in urine
Increased frequency of urination
Up more than twice a night to urinate
Urine retention
Frequent urine infections
None of the above general genitourinary issues
Other
Genitourinary (Women)
*
Unusual vaginal discharge
Vaginal pain, bleeding, soreness, or dryness
Genital sores
Heavy or irregular periods
No menses (periods stopped)
Currently pregnant
Sterility/infertility
Any other sexual or sex organ concerns
None of the above sex-specific genitourinary issues
Other
Genitourinary (Men)
*
Slow urine stream
Scrotal pain
Lump or mass in the testicles
Abnormal penis discharge
Trouble getting/maintaining erections
Inability to ejaculate/orgasm
Any other sexual or sex organ concerns
None of the above sex-specific genitourinary issues
Neurological
*
Paralysis
Fainting spells or blackouts
Dizziness/Vertigo
Drowsiness
Slurred speech
Speech problems (other)
Short-term memory trouble
Memory difficulties (loss)
Frequent headaches
Muscle weakness
Numbness/tinging sensations
Neuropathy (numbness in feet)
Tremor in hands/shaking
Muscle spasms or tremors
None of the above neurological issues
Other
Integumentary (Skin/Breast and Hair)
*
Lesions
Unusual mole(s)
Easy bruising
Increased perspiration
Rashes
Chronic dry skin
Itchy skin or scalp
Hair or nail changes
Hair loss
Breast tenderness
Breast discharge
Breast lump or mass
None of the above integumentary issues
Other
Psychiatric
*
In-depth review of psychiatric system appears earlier in document (to be checked by clinician only)
Feeling depressed
Difficulty concentrating
Phobias/Unexplained fears
No pleasure from life anymore
Anxiety
Insomnia
Excessive moodiness
Stress
Disturbing thoughts
Manic episodes
Confusion
Memory loss
Nightmares
None of the above psychiatric issues
Other
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GAD-7
Please read each statement and select a number 0, 1, 2, or 3 which indicates how much the statement applied to you over the past two weeks. There are no right or wrong answers. Do not spend too much time on any one statement. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified health professional.
GAD-7
*
0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
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Patient Health Questionnaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
PHQ-9
*
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself--or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite--being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way
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Adverse Childhood Experience (ACE) Questionnaire
While you were growing up, during your first 18 years of life:
Did a parent or other adults in the house often swear at you, insult you, put you down, or humiliate you OR act in a way that made you afraid you might be physically hurt?
Yes
No
Did a parent or other adults in the house often push, grab, slap, or throw something at you OR ever hit you so hard that you had marks or were injured?
Yes
No
Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way OR try to or actually have oral, anal, or vaginal sex with you?
Yes
No
Did you often feel that no one in your family loved you or thought you were important or special OR your family didn't look out for each other, feel close to each other, or support each other?
Yes
No
Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you OR your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes
No
Were your parents ever separated or divorced?
Yes
No
Was your mother or stepmother: often pushed, grabbed, slapped, or had something thrown at her OR sometimes or often kicked, bitten, hit with a fist, or hit with something hard OR ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes
No
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes
No
Was a household member depressed or mentally ill or did a household member attempt suicide?
Yes
No
Did a household member go to prison?
Yes
No
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I have completed, or had completed on my behalf, this questionnaire to the best of my ability. This information is true and correct, and can be used in conducting my Diagnostic Assessment.
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