Patient History Form
Your Name (person filling this out)
*
First Name
Last Name
Your Email
*
example@example.com
MN Intake Evaluation Form or Therapist Initial Assessment
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Patient Information:
The below questions pertain to the patient to be seen.
Name
*
First Name
Last Name
Patient's Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Preferred Pronouns (optional)
He/Him
She/Her
They/Them
Social Security Number
*
Marital Status
Divorced
Legally Separated
Married
Single
Widowed
Partnered
Other
Anulled
Interlocutory
Polygamous
Hearing Status
*
Deaf
Hard of hearing
Hearing
Preferred Language / Mode of Communication
*
English
ASL
Spanish
SimCom
Other
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Below applies to Patient
Height:
*
Weight:
*
Current working diagnosis in therapy:
*
Briefly describe present symptoms:
*
Psychiatric Hospitalizations (include where,when, & for what reason):
*
Who is the patient's Therapist?
*
Has patient ever had ECT?
Does Patient have any drug allergies
*
yes
no
Drug Allergies
Please list any medications along with dose that patient is currently taking. Include non-prescription medications & vitamins or supplements. If none type "none".
*
Name / Dose, Name / Dose
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements. If none type "none".
Rows
Name of drug
Dose(including strength & # of pills per day)
How long have you been taking this?
1
2
3
4
5
6
7
Patient currently has or has had:
*
Diabetes
High blood pressure
High cholesterol
Hypothyroidism
Goiter
Cancer
Leukemia
Psoriasis
Angina
Heart problems
Heart murmur
Pneumonia
Pulmonary embolism
Asthma
Emphysema
Stroke
Epilepsy (seizures)
Cataracts
Kidney Disease
Kidney stones
Crohn’s disease
Colitis
Anemia
Jaundice
Hepatitis
Stomach or peptic ulcer
Rheumatoid fever
Tuberculosis
HIV/AIDS
None
Other
If cancer was selected, please specify what type:
Were there problems with Patient's birth? (Specify)
Where was Patient born & raised?
What is Patient's highest education?
High School
Some college
College graduate
Advanced degree
Is Patient currently working?
Yes
No
What is Patient's current occupation?
If yes, hours/week
If not, is Patient:
Retired
disabled
Sick leave
Does Patient receive disability or SSI.
Yes
No
If yes, for what disability & how long?
Has Patient ever had legal problems? (If yes, specify)
*
Religion:
Family history
Rows
Age(s)
Health & Psychiatric
Age(s) at death
Cause
Father
Mother
Siblings
Children
Extended Family Psychiatric Problems Past & Present:
*
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Review of Systems
In the past month, has patient had any of the following problems?
*
recent weight gain
Recent weight loss
Fatigue
Weakness
Fever
Night sweats
Numbness
Joint pain
Muscle weakness
Joint swelling
Ringing in ears
Loss of hearing
Pain in eyes
Eye redness
Loss of vision
Double or blurred vision
Eye dryness
Frequent sore throats
Hoarseness
Difficulty in swallowing
Pain in jaw
Chest pains
Palpitations
Shortness of breath
Fainting
Swollen legs or feet
Cough
Headaches
Dizziness
Fainting or loss of consciousness
Numbness or tingling
Fainting or loss of consciousness
Memory loss
Nausea
Heartburn
Stomach pain
Vomiting
Yellow Jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools
Skin redness
Rash
Nodules/bumps
Hair loss
Color changes of hands or feet
Anemia
Blood clots
Frequent or painful urination
Blood in urine
None
Other
Women only:
Abnormal Pap smear
Irregular periods
Bleeding between periods
PMS
Other
Is patient currently pregnant?
*
yes
no
Age of first period:
Women’s reproductive history
# Pregnancies
Women’s reproductive history
# miscarriages
Women’s reproductive history
# Abortions
Women’s reproductive history
Have you rescheduled menopause?
Yes
No
If yes, at what age?
Do you have regular periods?
Yes
No
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Anxiety Symptom checklist:
Excessive worry
Restlessness
Autonomic hyperactivity
Fear
Sleep Disturbance
Phobia
Obsessive compulsive
If yes to fear, Specify
If yes to phobia, Specify
Self-Harmful symptom checklist:
Cutting
Burning
Psychotic symptom checklist:
Hallucinations
Paranoid thinking
Delusions
Suicide attempt
Suicidal ideation
Suicidal gestures
If yes to hallucinations, Specify auditory, visual or both
Sleep symptom checklist:
Difficulties going to sleep
Waking up at night
Waking up early
Attention Deficit/Hyperactivity symptom checklist:
Short attention span
Inattentive
Easily distracted
Failure to follow through
Excessive talking
Negative attention seeking behaviors/Risk takers
Projecting blame
Poor social skills
Post traumatic stress symptom checklist:
Decrease concentration
Flashbacks
Avoidance of issue
Vigilance
Sleep Disturbance
Recurring nightmares
Eating Disorders symptom checklist:
Self induced vomiting
Use of laxatives
Refusal to maintain healthy weight
Preoccupation with body image
Irrational fear of becoming overweight
Sexually Inappropriate behaviors symptom checklist:
Touching
Exposing
Poor Verbal Skills symptom checklist:
Excessive
Receptive
Depression symptom checklist:
Sad/flat affect
Irritability
Isolative/withdrawn
Reduced Appetite
Sleep Disturbances
Unresolved grief
Feeling hopeless
Hygiene problems
Inactive/low motivation
Mood disruption
Oppositional Defiant symptom checklist:
Hostile toward others
Consistently arguing with others
Refusing to comply with rules
Blaming others
Demanding
Verbal aggression
Other:
failure to comply
Assaultive
Homicidal
Intimidate others
Harmful to others
Stealing
Issues at work
Conflict with authority
Risk taking
Blaming others
Little/no remorse
Destruction of property
Low frustration tolerance
Enuresis
Encopresis
Hx of failure to thrive
Fire setting
Fire play
gang association
Manipulative/lying
Learning disability
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Medication History
Rows
Dates
Effectiveness
Side Effects
Abilify(Aripiprazole)
Ambien(Zolpidem)
Ativan(Lorazepam)
Buspar(Buspirone)
Celexa(Citalopram)
Clonidine
Concetra(Methylphenidate)
Cymbalta(Duloxetine)
Daytrana patch(Methylphenidate patch)
Depakote(Valproic)
Desiryl (Trazadone)
Effexor(Venlafexine)
Emsam (Selegiline patch)
Focalin(Dexmethylphenidate)
Geodon(Zyprasidon)
Intuniv(Guanfessin ER)
Kapvay(Clonidine ER)
Klonipin(Clorazepam)
Lamictal(Lamotrine)
Latuda
Lexapro(escitalopram)
Lithium
Luvox (Fluvoxamine)
Neurontin(Gabapentin)
Paxil(Paroxetine)
Pristiq (Desvenlafexine)
Prozax(Fluoexetine)
Remeron(Mirtazapine)
Restoril(Temazepam)
Risperdal(Risperidone)
Ritalin(Methylphenidate)
Seroquel(Quetiapine)
Strattera(Atomoxetine)
Tegretol(Carbamazepine)
Tenex (Guanfacine)
Topamax(Topiramate)
Trileptal(Oxcarbazepine)
Valium (Diazepam)
Vistaril(Hydroxyzine)
Vyvanse(Lisdexamphetamine)
Wellbutrin(Bupropion)
Xanax(Alprozolam)
Zoloft(sertraline)
Zyprexa(Olazapine)
Other medications:
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Should be Empty: