• Willow Medical & Wellness Intake Form

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  • Please complete all information on this form and return it to the office 3 days prior to your appointment

  • Personal Psychiatric History

  • Past Psychiatric History

  • Past Psychiatric Medications

    Please list the dosages, dates, response, and side effects associated (click on the arrow for any medication taken)

  • SSRIs

    • Prozac (fluoxetine) 
    • Paxil (paroxetine) 
    • Zoloft (sertraline) 
    • Celexa (citalopram) 
    • Lexapro (escitalopram) 
    • Luvox (fluvoxamine) 

  • SNRIs

    • Effexor (venlafaxine) 
    • Cymbalta (duloxetine) 
    • Pristiq (desvenlafaxine) 
    • Fetzima (levomilnacipran) 

  • Other

    • Wellbutrin (bupropion) 
    • Remeron (mirtazapine) 

  • Tricyclic Antidepressants

    • Anafranil (clomipramine) 
    • Pamelor (nortriptyline) 
    • Tofranil (imipramine) 
    • Elavil (amitriptyline) 
    • Vivactil (protriptyline) 

  • Serotonin Modulators

    • Viibryd (vilazodone) 
    • Serzone (nefazodone) 
    • Trintellix (vortioxetine) 

  • MAOIs

    • Emsam (selegiline) 
    • Parnate (tranylcypromine) 
    • Nardil (phenelzine) 

  • Mood Stabilizers

    • Tegretol (carbamazepine) 
    • Trileptal (oxcarbazepine) 
    • Lithium 
    • Depakote (valproate) 
    • Lamictal (lamotrigine) 
    • Neurontin (gabapentin) 
    • Topamax (topiramate) 

  • Antipsychotics / Mood Stabilizers

    • Haldol (haloperidol) 
    • Clozaril (clozapine) 
    • Zyprexa (olanzapine) 
    • Seroquel (quetiapine) 
    • Risperdal (risperidone) 
    • Abilify (aripiprazole) 
    • Geodon (ziprasidone) 
    • Saphris (asenapine) 
    • Latuda (lurasidone) 
    • Rexulti (brexpiprazole) 
    • Vraylar (cariprazine) 
    • Fanapt (iloperidone) 
    • Invega (paliperidone) 

  • Sedative / Hypnotics

    • Ambien (zolpidem) 
    • Sonata (zaleplon) 
    • Lunesta (eszopiclone) 
    • Rozerem (ramelteon) 
    • Restoril (temazepam) 
    • Desyrel (trazodone) 
    • Belsomra (suvorexant) 

  • ADHD Medications

    • Ritalin (methylphenidate) 
    • Concerta (methylphenidate) 
    • Focalin (dexmethylphenidate) 
    • Dexedrine (dextroamphetamine) 
    • Vyvanse (lisdexamfetamine) 
    • Adderall (Dextroamphetamine-amphetamine) 
    • Strattera (atomoxetine) 
    • Intuniv (guanfacine) 

  • Anti anxiety medications

    • Xanax (alprazolam) 
    • Xanax XR 
    • Ativan (lorazepam) 
    • Klonopin (clonazepam) 
    • Valium (diazepam) 
    • Tranxene (clorazepate) 
    • Buspar (buspirone) 

    • Other Medications

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  • Family Background and Childhood History

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