Patient Intake Form
Date
*
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Month
-
Day
Year
Date
Name
*
First Name
Last Name
Birth Date
*
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Month
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Day
Year
Date
Social Security Number
*
xxx-xx-xxxx
Gender
*
Female
Male
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Married
Seperated
Divorced
Never Married
Widowed
Other
Militry Service
Active Duty
Reserves
Veteran
AD Dependent
Never Served
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Emergency Contact Information
*
Preferred Pharmacy
Insurance Provider
*
Insurance carrier or Self Pay
Insurance Card (Front)
Insurance Card (Back)
Race
*
American Indian
Asian
Black / African American
White
Native Hawaiian or Pacific Islander
Decline to specify
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Decline to specify
Preferred Language:
.
Security Question: Mother's maiden name
.
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Current Symptoms (Check all that apply)
*
Sad/depressed mood
Loss of interest/pleasure
Feeling worthless/guilt
Withdrawn/Social Isolation
Irritability/outbursts of anger
Weight gain/loss
Appetite increase/decrease
Sleep disturbance
Crying spells
Difficulty concentrating
Inflated self-esteem
Grandiosity
Talkative
Flight of ideas
Distractibility
Unrestrained buying sprees
Sexual indiscretions
Excessive pleasure activities
Muscle tension
Heart palpitations
Sweating not due to heat
Trembling/shaking
Shortness of breath
Feeling of choking
Chest pain/discomfort
Feeling dizzy/lightheaded
Compulsions
Fear of losing control
Recurrent/persistent thoughts
Recurrent/intrusive memories
Laxative/diuretic abuse
Trouble following directions
Touchy/easily annoyed
Thoughts of Suicide
Homicidal Ideation
Poor impulse control
Relationship difficulties
Deliberate property destruction
Other
Patient Medical History (Check all that apply)
*
Allergies
Anemia
Anxiety
Arthritis
Asthma
Liver Disease
Thyroid Disease
Kidney Disease
Blood Clots
Cancer
Chest pain
COPD
Crohn's Disease
Depression
Diabetes
Seizure Disorder
Gallbladder Disease
GERD
Heart Attack
Hepatitis
High Cholesterol
Irritable Bowel
Migraine Headaches
Osteoarthritis
Osteoporosis
Peptic Ulcers
Prostate Enlargement
High Blood Pressure
Artial Fibrillation
Coronary Artery Disease
Other
List any past surgical procedures (including year) you may have had:
List out allergies
List out all current medication (Name, Strength, and Frequency) (N/A if none)
*
Previous Behavioral Health Medication
Antidepressants Medications
amitriptyline (Elavil)
Dextromethorphan / bupropion (Auvelity)
bupropion (Wellbutrin)
clomipramine (Anafranil)
citalopram (Celexa)
desipramine (Norpramin)
desvenlafexine (Pristiq)
doxipin (Sinequan)
duloxetine (Cymbalta)
escitalopram (Lexapro)
fluoxetine (Prozac)
fluvoxamine (Luvox)
imipramine (Tofranil
levomilnacipran (Fetzima)
mirtazapine (Remeron)
nortriptyline (Pamelor)
paroxetine (Paxil)
selegiline (Emsam)
sertaline (Zoloft)
Trazodone (Desyrel)
venlafexine (Effexor)
vilazodone (Viibryd)
vortioxetine (Trintellix)
Other
Anti-anxiety Medications
alprazolam (Xanax)
buspirone (BuSpar)
chlordiazepoxine (Librium)
clonazepam (Klonopin)
clorazepate (Tranxene)
diazepam (Valium)
lorazepam (Ativan)
oxazepam (Serax)
propanolol (Inderal)
Other
Sleep Medications
daridorexant (Quviviq)
eszopiclone (Lunesta)
ramelteon (Rozerem)
suvorexant (Belsomra)
temazepam (Restoril)
trazodone (Desyrel)
zolpidem (Ambien)
Other
Antipsychotic Medications
aripiprazole (Abilify)
asenapine (Saphris)
brezpiprazole (Rexulti)
cariprazine (Vraylar)
chlorpromazine (Thorazine)
clozapine (Clozaril)
fluphenazine (Prolixin)
paloperidol (Haldol)
iloperidone (Fanapt)
lumateperone (Caplyta)
lurasidone (Latuda)
olanzapine (Zyprexa)
paliperidone (Invega)
perphenazine (Trilafon)
quetiapine (Seroquel)
risperidone (Risperdal)
thioridazine (Mellaril)
thiothixene (Navane)
Ziprasidone (Geogon)
Other
Mood Stabilizers Medications
carbamazepine (Tegretol)
divalproex / valproic acid (Depakote)
gabapentin (Neurontin)
lamotrigine (Lamictal)
lithium (Eskalith)
oxcarbazepine (Triliptal)
topiramate (Topamax)
ADHD Medications
amphetamine salts (Adderall)
atomozetine (Strattera)
clonidine (Kapvay)
dexmethylphenidate (Focalin)
dextroamphetamine (Dexadrine)
guanfacine (Intuniv)
lisdexamfetamine (Vyvanse)
Methylphenidate (Ritalin, Concerta)
serdexmethylphenidate / dexmethylphenidate (Azstarys)
viloxazine (Qelbree)
MAT Medications
acamprosate (Campral)
buprenorphine (Subutex)
buprenorphine / naloxone (Suboxone / Sublocade)
disulfiram (Antabuse)
methadone
naltrexone (Vivitrol, ReVia)
Have you received any outpatient treatment for a psychiatric condition ?
*
Yes
No
Please include condition, facility, and dates
Have you been hospitalized?
*
Yes
No
Please include condition, facility, and dates
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Tobacco use
Tobacco Use (Select all that apply)
*
Never Smoked
Ex-Smoker
Ex-user of moist powdered tobacco
light cigarette smoker (1-9 / day)
Moderate cigarette smoker (10-19 / day)
Heavy cigarette smoker (20-39 / day)
Ver heavy cigarette smoker (40+ / day)
Vape
Cigar Smoker
Pipe Smoker
Chews tobacco
Snuff
Other
Alcohol use
1.) How often d you have a drink containing alcohol?
*
Never
Monthly or less
2 - 4 times per month
2 - 3 times per week
4 or more times per week
2.) How many standard drinks containing alcohol do you have per day?
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0
1 - 2
3 - 4
5 - 6
7 - 9
10 or more
3.) How often do you have 6 or more drinks on a single occasion?
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Never
Monthly or less
Weekly
Daily
Financial Resources
Describe your difficulty paying for the very basics like food, housing, medical care and utilities.
*
Very Hard
Hard
Somewhat Hard
Not Hard at All
Decline to Answer
Education
What is the highest level of education completed?
*
Please Select
Never attended / Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
GED or Equivalent
Some College
Associate Degree: Occupational, Technical, or vocational program
Associate Degree: Academic Program
Bachelor's Degree
Master's Degree
Professional School Degree
Doctoral Degree
Decline to answer
Physical Activity
1.) How many days in the last week have you engaged in moderate to strenuous exercise such a a brisk walk or working out at the gym
*
2.) On those days that you engage in moderate to strenuous exercise how many minutes did you exercise
*
Stress
Do you feel stress, tense, restless, nervous, anxious or unable to sleep at night because your mind is troubled all the time.
*
Not at all
Only a little
To some extent
Rather Much
Very Much
Decline to Answer
Social Isolation and Connection
1.) Are you married, widowed, divorced, separated, never married or living with partner?
*
Please Select
Married
Widowed
Divorced
Separated
Never Married
Living with partner
Decline to answer
2.) In a typical week, how many times do you talk on the telephone with family, friends, or neighbors
*
3.) In a typical week, how often do you get together with friend or relatives?
*
4.) In a typical year how many times do you attend church or religious services?
*
5.) Do you belong to any clubs or organizations such as with church, group unions, fraternal or athletic groups or school groups?
*
Yes
No
Exposure to Violence
1.) Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?
*
Yes
No
Decline to answer
2.) Within the last year, have you been afraid of your partner or ex-partner?
*
Yes
No
Decline to answer
3.) Within the last year, have you been raped or forced to have any kind of sexual activity against your will by your partner or ex-partner?
*
Yes
No
Decline to answer
4.) Within the last year, have you been kicked, hit, slapped, or otherwise hurt by your partner or ex-partner?
*
Yes
No
Decline to answer
Gender Idenity
Gender Idenity
*
Please Select
Male
Female
Transgender Male
Transgender Female
Genderqueer (non-binary)
Decline to answer
Sexual Orientation
Sexual Orientation
*
Please Select
Straight / heterosexual
Gay, Lesbian or homosexual
Bisexual
Decline to Answer
Average hour of sleep per night?
*
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