Capital Health Group Intake Form

New Patient Intake Form

PSYCHIATRIC HISTORY

FAMILY HISTORY: Include: Bipolar disorder, Anxiety, Personality Disorders, Substance Abuse, ADHD/ADD, Autism, Depression, Schizophrenia, Suicide Attempts.

SOCIAL HISTORY FOR CHILDREN AND ADOLESCENTS

PSYCHIATRIC HOSPITALIZATION HISTORY

SOCIAL HISTORY FOR ADULTS

New Patient Intake Form
Name*
Date*

MonthDayYear
Preferred Name
MF
Sexual orientation
Gender identity
Address
Email Address
example@example.com
YesNo
Home Phone
Please enter your home phoneFormat: (000) 000-0000.
YesNo
Cell Phone
Please enter your cell phoneFormat: (000) 000-0000.
YesNo
All clients will be sent a text message and email for appointment reminders three days prior to scheduled appt.
Emergency Contact Information:
Name
Relationship
Address
Home Phone
Please enter your home phone Format: (000) 000-0000.
Cell Phone
Please enter your cell phoneFormat: (000) 000-0000.
Work Phone
Please enter your work phoneFormat: (000) 000-0000.
IF ANOTHER PERSON IS RESPONSIBLE FOR CHARGES:
Name
Relationship
Address
Home Phone
Please add home phone numberFormat: (000) 000-0000.
Cell Phone
Please add cell phone numberFormat: (000) 000-0000.
Work Phone
Please add cell phone numberFormat: (000) 000-0000.
How did you hear about Capital Health Group?
Why are you currently seeking treatment?
Please describe the symptoms you are experiencing:
When did they start?
Were your symptoms sudden or gradual?
What makes the symptoms better or worse?
Were you formally diagnosed? Date and by whom?
How are your daily symptoms interfering with your daily routine?
WorkHomeSchool (Check all that apply)
Sleep: How many hours do you sleep per night?
Difficulty falling asleepWaking up in the middle of the nightNightmaresSnoringRestless sleepDaytime fatigueSleep ApneaExcessive daytime sleepNarcolepsy
Watching television at bedtimeCaffeine intake in afternoon/eveningSleep Habits:Using iPad/Computer/Cell phone within 2 hours of going to bedExercise in eveningUse of sleep medications/herbal or homeopathic remedies for sleep
Same as beforeDecreasedIncreasedDieting
BingingInduced VomitingExercise others feel is excessiveCalorie restrictionLaxative use
Any weight changes (Yes or No):
Highest Weight
Lowest Weight
Same as beforeIncreasedDecreased
PSYCHIATRIC HISTORY
Major depressionBipolar disorderGeneralized anxiety disorderObsessive compulsive disorderAutismSchizophreniaADHD/ADDEating disorderSchizoaffective disorderPersonality disorderPost-traumatic stress disorder
YesNo
Number of attempts in lifetime:
YesNo
PSYCHIATRIC HOSPITALIZATION HISTORY
YesNo
If Yes, Name of Hospital(s)
Dates of Hospitalization
Reason for hospitalizations
What meds have you trialed? List your response and duration of time used? (EX. Zoloft-ineffective, felt worse, 90 days)
1
2
3
4
5
6
DiabetesStrokeCataractsAnemiaAsthmaHeart murmurCrohns diseaseConcussionsJaundiceHigh cholesterolColitisHypothyroidismPneumoniaSeizures/EpilepsyHigh blood pressureTBIPulmonary EmbolismSports InjuriesPsoriasisEmphysemaCOPDHepatitis CancerLeukemia
Any other medical and/or surgical history (Please list surgical history and dates):

Current Medications (include nutritional supplements, herbal supplements and over-the-counter medications):

Rows	Name of Medication and Approx. Start Date	Dose	Frequency	Reason Prescribed
1
2
3
4
5

Allergies (medication and food):
Please provide pharmacy of choice and include address and phone number:

Chemical Use History:

Please enter ALL that apply

Rows	Method of use and amount	Frequency of use	Age of first use	Used in last 48 hours?	Used in last 30 days?
Marijuana
PCP/LSD/Mescaline
Inhalants
Caffeine
Nicotine
Over the counter
Prescription drugs
Other drugs

YesNo
ArrestsBlackoutsConsuming more than intendedDUIEmployment issuesFightingFamily/Marital ConflictHealth ProblemsFeeling guiltyPhysical Health ProblemsFinancial problemsWithdrawal historyIncreased ToleranceSeizuresUnintentional Overdose
YesNo
FAMILY HISTORY: Include: Bipolar disorder, Anxiety, Personality Disorders, Substance Abuse, ADHD/ADD, Autism, Depression, Schizophrenia, Suicide Attempts.
Mother
Father
Sister
Brother
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Childhood physical abuseChildhood emotional/verbal abuseChildhood sexual abuseChildhood exposure to domestic violenceNeglect in childhoodExposure to warCombat traumaEarly parental lossForced prostitutionWitnessed the death of loved oneSurvivor of suicideExposure to potential deadly/deadly accidentExposure to terrorist actExposure to fireExposure to natural disasterPartner physical/emotional/verbal abuseStranger rape/assaultRape/assault by family member

Former Psychiatrist and Therapist (Please list name, address and phone number)

Rows	Psychiatrist or Therapist Name	Phone Number	Address

SOCIAL HISTORY FOR CHILDREN AND ADOLESCENTS
Who lives at home?
Are parent married?
Are there step-parents involved?
School attended
Grade
YesNo
YesNo
YesNo
Other services involved at school?
YesNo
YesNo
YesNo
Extracurricular Activites:
SOCIAL HISTORY FOR ADULTS
Who lives in the home
Highest Level of Education
Full-timePart-timeUnemployed
Occupation
Employer:
How long have you had this job?
List current stressors:
ADDITIONAL INFORMATION: Please inform me of any other concerns or pertinent information here:
Please attach any previous assessments or collateral information (i.e psychological evaluation, psychiatric evaluation, discharge summary, etc.)

Cancelof
Should be Empty:

Method of use and amount

Frequency of use

Age of first use

Age of last use

Used in last 48 hours?

Used in last 30 days?

Barbiturates

Valium/Librium

Cocaine/Crack

Heroin/Opiates