The Happiness Psychiatrist® New Patient Intake Form

THE HAPPINESS PSYCHIATRIST®:

SHEENIE AMBARDAR, M.D.

Concierge Telepsychiatry, Teletherapy, Medical Weight Care & Coaching

(424) 666-8058

www.happinesspsychiatrist.com

Serving California and New York
New Patient Evaluation Form
Welcome! Please fill out the following confidential, HIPAA-compliant intake form prior to your first appointment with Dr. Ambardar. By answering these questions accurately and thoughtfully, you will be helping set the therapeutic process in motion. If you are uncomfortable answering any of these questions, please feel free to leave them blank. We can discuss them in more detail at our initial evaluation.
Patient Identification:
Name*

First NameLast Name
Birthdate:

MonthDayYear
Date
Age:
Gender:
Occupation:
Relationship Status:
Preferred Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email address:
example@example.com
Home Address:

Street Address

Apartment or Unit Number

CityState / Province

Postal / Zip Code
Physician or Therapist ReferralPatient Referral/Word of MouthGoogle SearchPsychology Today Online DirectoryAnxiety & Depression Association of America DirectoryOther
If applicable, please specify name of referring doctor or therapist:
Please list an Emergency Contact:
Name of Contact and Relationship to You:
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Pharmacy:

Name of Pharmacy

Street Address Line 2

Address of PharmacyState / Province

Phone Number of Pharmacy
PURPOSE OF CONSULTATION: What is the primary reason you would like to see Dr. Ambardar?
What would successful treatment look like to you?
Presenting Symptoms:
Depressed or sad moodDifficulty enjoying usual activitiesUnintentional weight loss or weight gainSleeping too much or not enoughFeeling agitated or sluggishLacking energy/always tiredFeeling guilty or worthlessPoor focus and concentrationThoughts of death or suicideInflated self-esteemDecreased need for sleep or going for days without sleepingExcessive talkingRacing thoughtsFeeling highly distractibleTry to do or accomplish way too much in a dayImpulsive behaviorSeeing or hearing things that may not be realFeeling like people are watching you or out to get youOften tense or unable to relaxExcessive worryingDifficulty falling asleepDifficulty staying asleepPanic AttacksAfraid/unable to leave homeExtreme unreasonable fearsIntense fear of social situationsCannot prevent repetitive thoughtsCannot prevent repetitive behaviorsIntrusive, upsetting memories of past eventsAlways on guard or never feel safeBody overreacts to "stress"Difficulties with focus and concentrationHyperactivity or ImpulsivityChronic BoredomMood SwingsForgetfulness
Life Problems That Currently Affect You:
Problems within my familyProblems among my friends/communityEducational problemsOccupational/Job problemsHousing problemsFinancial/Economic problemsProblems with the law, legal systemDestructive/violent thoughts or behaviorsAttempts to hurt, harm, or mutilate selfAnger outburstsDiscipline problems at workCareless, high-risk behavior
Past Psychiatric History:
YesNo
If yes, please elaborate:
YesNo
If yes, please elaborate:
YesNo
If yes, please elaborate:
YesNo
If yes, please elaborate:
DepressionBipolar I DisorderBipolar II DisorderAnxietyADHDAutismPhobiasAlcohol or Drug AddictionBPD (Borderline Personality Disorder)OCD (Obsessive Compulsive Disorder)PsychosisPTSD or TraumaPanic AttacksDyslexia or Learning DisabilitySchizophreniaSleep DisorderChronic InsomniaBinge-Eating DisorderBulimiaAnorexiaBody DysmorphiaS.A.D. (Seasonal Affective Disorder)PMDD (Premenstrual Dysphoric Disorder)PPD (Postpartum Depression)Other
Which psychiatric medications have you taken in the past and what were the benefits and/or side effects you experienced?
YesNo
If yes, please list all current medications along with dosages and prescribing physician:
YesNoNot sureMaybeOther
If you answered yes or maybe, please elaborate below:
General Medical History:
YesNo
If yes, please list name of PCP:
PCP Contact Number:
Format: (000) 000-0000.
PCP Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Physical Exam:

MonthDayYear
Date
Date of Last Blood Work:

MonthDayYear
Date
If you have a copy of your latest blood work, please upload it here:

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Do you have any general medical problems? Please list:
AnemiaAsthmaIrregular Heart BeatLow Vitamin B12 levelsLow Iron levelsChronic FatigueLow Blood SugarUlcers/Gastritis/RefluxSeizures or Seizure DisorderRestless legsMigraines or HeadachesDiabetesPrediabetesHigh Blood PressureLow Blood PressureHigh CholesterolCancerInflammatory ConditionHeart DiseaseThyroid Issues (Hashimoto's, Hypothyroidism, Hyperthyroidism, etc)PMS or PMDD (Premenstrual Dysphoric Disorder)PPD (Postpartum Depression)PCOS (Polycystic Ovary Syndrome)Irritable Bowel/GI symptomsTBI (Traumatic Brain Injury)Autoimmune conditions (Lupus, Celiac, Psoriasis, Hashimoto's, etc)Other
YesNo
If yes, please list:
YesNo
If yes, please list:
YesNo
If yes, please list medications and allergic reactions:
YesNo
If yes, please list all surgical procedures:
YesNo
If yes, please rate your average pain level using the scale below:
If yes, please also describe your pain below:
YesNo
If yes, please describe:
How tall are you?
How much do you weigh?
How would you describe your current physical health?
Alcohol, Drug, and Tobacco Use:
are a non-drinkerare a social drinkerare a regular drinkerhave a drinking problemare an alcoholic
Regardless of the box you checked, please describe the frequency of your alcohol use and what kind of alcohol and how much you drink, including date of last use:
YesNo
If yes, please describe (Legal, Financial, Health, or Relationship problems):
don't use drugshave a drug problemhave a drug addictionuse drugs recreationally
Substance Use:
Marijuana/THCCocaine/CrackDesigner Drugs (such as Club Drugs: G, X)Hallucinogens (LSD, Mushrooms)Inhalants (Gasoline, Glue, Aerosol)Opiates/Methadone (Vicodin, Oxycontin, Heroin)Benzodiazepines (Klonopin, Valium, Xanax, Ativan)Methamphetamines (Speed, Ice, Adderall)Prescription PillsTobaccoOther
BlackoutsBad reactionsWithdrawal symptomsCravingsOverdosesTolerance ("Could not get high no matter how much I used")Preoccupation (Spent lots of time finding and using substance)Failed attempts to cut down or control useDetoxification in a hospitalOther
On average, how many cups of coffee or other caffeinated drinks (tea, energy drinks, soda) do you consume daily? What time of day do you usually have your last caffeinated beverage?
Social History:
Where were you born and where did you grow up?
YesNo
If no, how old were you when they separated?
Father's occupation while you were growing up:
Mother's occupation while you were growing up:
GoodAverageBad
Please briefly describe your relationship with your father:
GoodAverageBad
Please briefly describe your relationship with your mother:
None
Brothers
Sisters
GoodAverageBad
Please briefly describe your relationship with your siblings:
YesNo
If yes, please describe:
YesNo
If yes, please describe:
YesNo
If yes, please describe:
Physical AbuseSexual AbuseEmotional/Verbal AbuseFinancial AbuseNoneOther
If you were a victim of abuse, please elaborate below if you feel comfortable sharing and specify how old you were when abuse occurred:
Work/Job/Occupational TraumaSchool Trauma (e.g. bullying, hazing, etc)Childhood TraumaImmigrant TraumaRacial TraumaIntergenerational/Historical TraumaSexual TraumaReligious TraumaMedical TraumaFinancial TraumaNoneOther
If you have experienced trauma, please elaborate below if you feel comfortable sharing:
What's the highest level of education you've completed?
If applicable, where did you attend college or university?
What kinds of jobs and/or professions have you had in the past?
YesNo
If yes, where?
How would you describe your sexual orientation?
YesNo
If yes, what is your partner's first name and occupation?
How long have you been together?
How would you describe your relationship?
YesNo
If yes, please describe briefly:
YesNo
If yes, what kind of pet(s) and what are their name(s)?
YesNo
If yes, what are their names & ages?
What are you passionate about? What are some things you enjoy doing in your spare time? (hobbies, interests, etc)?
How would you describe your relationship to spirituality, if any?:
How would you describe your daily food intake? If you could improve one thing about your food intake, what would it be?
How many days a week do you engage in body movement, physical activity, or exercise?
Family History:
YesNo
Mother:
Father:
Siblings:
Maternal Grandmother:
Maternal Grandfather:
Maternal Aunts:
Maternal Uncles:
Maternal Cousins:
Paternal Grandfather:
Paternal Grandmother:
Paternal Aunts:
Paternal Uncles:
Paternal Cousins:
Please upload any relevant prior physician's notes or any other documents you would like to share here:

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Additional information you would like Dr. Ambardar to know:
Thank you for taking the time to fill out this confidential form accurately and thoughtfully.
Should be Empty:

New Patient Evaluation Form

Patient Identification:

Presenting Symptoms:

Life Problems That Currently Affect You:

Past Psychiatric History:

General Medical History:

Alcohol, Drug, and Tobacco Use:

Substance Use:

Social History:

Family History: