Patient Registration Form
Date of Appointment
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Information
Patient's Name
*
First Name
Middle Name
Last Name
Sex
Marital Status
Date of Birth (Age)
Social Security Number
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Referred By
Type a question
Primary Care Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy
Pharmacy Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Employer/School Information
Employer/School
Occupation
Employee/School Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer/School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Patient
Billing and Insurance
Primary Health Insurance
Insurance Company
Plan
Plan Number
Group Number
Insured's Employer/School
Insured's Name
(as it appears on insurance card or ID)
Relation to Patient
Insured's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insured's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured's Social Security Number
Insured's Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Secondary Health Insurance
Insurance Company
Plan
Plan Number
Group Number
Insured's Employer/School
Insured's Social Security Number
Insured's Name
(as it appears on insurance card or ID)
Relation to Patient
Insured's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party
Billing Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Patient
Signature of Patient or Authorized Guardian
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Name
Age
Sex
Date of Appointment
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Visit
What brings you to the office today?
Date symptoms started
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you lost any days from work/school?
Yes
No
Medications
Have you ever taken the following medicines?
SSRI (egg. Prozac/fluoxetine, Paxil/paroxetine, Celexa/citalopram, Lexapro/escitalopram)
Effexor/venlafaxine or Cymbalta/duloxetine
Tricyclics (eg. Elavil/amitryptyline, Pamelor/nortryptyline, Tofranil/imipramine, Anafranil/clomipramine)
Wellbutrin/buproprion
Desyrel/trazodone, Serzone/nefazodone
Mood Stabilizers (eg. Lithium, Tegretol/carbamazepine, Topramax/toprimate, Depakote/valproate, Lamictal/lamotrogine)
Antipsychotic mood stabilizers (eg. Seroquel/quetipine, Geodon/ziprasidone, Abilify/aripiprazole, Zyprexa/olanzapine, Haldol/haloperidol, Clozaril/clozapine, Prolixin/fluphenazine)
Sleeping Pills (eg. Ambien/zolpidem, Desyrel/trazodone, Sonata/zaleplon, Restoril/temazepam)
Anti-anxiety medicines (eg. Ativan/lorzepam, Klonipin/clonazepam, Xanax/alpazolam, Valium/diazepam, Buspar/buspirone)
ADHD medicines (eg. Ritalin/Concerta/methylphenidate, Adderall/amphetamine, Strattera/atomoxetine)
List other medicines you are taking:
Past Psychiatric History
Check all that apply:
ADHD
Anxiety
Bipolar
Depression
Eating Disorder
Phobia(s)
Obsessive Compulsive
Pre-Menstrual Dysphoric Disorder/PMS
Post Traumatic Stress
Schizophrenia
Schizoaffective Disorder
Substance Abuse
Suicide Attempt
Have you seen a psychiatrist, psychologist or therapist/counselor in the past?
No
Yes, when?
Allergies
Are you allergic to any of the following?
ACE Inhibitors
Adhesive Tape
Anesthetics
Aspirin
Barbiturates (Sleeping Pills)
Codeine
Iodine (including contrast dye)
Latex
Penicillin
NSAIDs (ibuprofen, Naprosyn, Advil)
Seizure Medicines
Sulfa
Details/Reactions:
Lifestyle Factors
Has anyone in your home ever physically, emotionally or sexually abused you?
Yes
No
Have you ever smoked?
Yes
No
# of years
# of packs/day
Do you smoke now?
Yes
No
# of packs/day
Do you use recreational drugs? (including abuse of prescription drugs)
Yes
No
Types?
# of times/week
How much alcohol do you drink per week?
# of drinks/week
How much caffeine do you drink per day?
# of drinks/day
How often do you exercise?
# of times/weel
Are you currently:
Working
Retired
Not working by choice
Volunteering
Unemployed
Disabled
Have you ever served in the military?
Yes
No
How would you identify your sexual orientation?
Straight / Heterosexual
Lesbian / Gay / Homosexual
Bisexual
Asexual
Transsexual
Unsure/Questioning
Prefer not to Answer
Other
Have you ever been arrested?
Yes
No
Do you have any pending legal problems?
Yes
No
Do you belong to a particular religion or spiritual group
No
Yes
Highest Educational Level Attained
Grade School
High School
Junior College
Undergraduate College / University
Graduate School
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Name
Age
Sex
Date of Appointment
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Past Medical History
Have you ever had any of the following?
Anemia
Chronic Fatigue
Chronic Pain
Diabetes
Epilepsy / Seizures
Fibromyalgia
Head Injury
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Liver Problems
Lung Problems
Stomach Problems
Thyroid Disease
Other
Hospitalizations & Surgeries
Hospitalizations & Surgeries
Have you ever had an EKG?
No
Yes, when?
Was the EKG:
Normal
Abnormal
Not Sure
Women Only
Are you currently pregnant or think you may be pregnant?
Yes
No
Are you planning to get pregnant in the near future?
Yes
No
Birth Control Methods:
Condoms
Pill
Shot
Patch
Ring
Under Skin
IUD
Tubal Ligation
Vasectomy in Partner
Not Applicable
Family History
Has anyone in your family (mother, father, grandparents) had any of the following:
ADHD
Alcohol Abuse
Anemia
Anger
Anxiety
Bipolar Disorder
Chronic Fatigue
Chronic Pain
Depression
Diabetes
Drug Addiction
Eating Disorder
Epilepsy / Seizures
Fibromyalgia
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Obsessive Compulsive Disorder
Phobias
Post Traumatic Stress
Schizophrenia
Suicide Attempts/Thoughts
Thyroid Disease
Violence
Review of Systems
Psychological
Anxiety Attacks
Avoidance/Avoidant Personality Disorder
Change in Appetite
Decrease Libido
Decrease Need for Sleep
Excessive Energy
Excessive Guilt
Excessive Worry
Fatigue
Forgetfulness
Hallucinations
Impulsivity
Racing Thoughts
Sleeping problems
Increased Irritability
Increased Libido
Increase in Risky Behavior
Loss of Interest in Most Things
Suicidal Thoughts
Suspiciousness
Thoughts of harming/killing someone
Trouble concentrating
Unable to enjoy activities
General
Chills
Fever
Night Sweats
Weight Gain
Weight Loss
Neurology
Burning Pain
Headache
Seizures
Tingling
Tremor
Visual Changes
Gastrointestinal
Abdominal Cramping/pain
Acid Taste
Bloating
Diarrhea
Frequent Belching
Indigestion
Nausea
Cardiovascular
Chest Pain
Leg Swelling
Light headedness
Palpitations
Musculoskeletal
Joint pain
Muscle Pain
Weakness
Respiratory
Chest Tightness
Coughing
Shortness of Breath
Wheezing
Ear, Nose & Throat
Hearing Problem
Hoarseness
Ringing in Ears
Other
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