2022_11_15_11_57

ROSWELL PYSCHIATRY CLINICAL INTAKE FORM
Name
Date of Birth

MonthDayYear
Date
Complaint
What is your major complaint? Have you previously suffered from this complaint and when did it start Previous therapist or Psychlatrist: Previous treatment for complain: Current Symptoms (Check all that apply)
AnxietyDepressionHallucinationsLoss of InterestSleep changesCryingAppetite IssuesExcessive EnergyImpulsivityPanic AttacksRacing ThoughtsGuiltSuspiciousnessAvoidanceIrritabilityfatigueRisky ActivityLabido Changes
Allergies: What medications are you currently taking: Previous diagnoses/ mental health treatment: test

Previous medications: Previous medical conditions: test

Previous surgeries: Any History of mental health conditions in your family? If so, who and what conditions:

testing

Drug or Alcohol History: Rehab or dextox History: Have you been recently discharged from any PHP or inpatient program: test
Should be Empty: