Phoenician Behavioral Health Intake
Name:
*
Date
*
-
Month
-
Day
Year
Email
Phone Number
Format: (000) 000-0000.
Chief Complaint: (What are you being seen for today?):
Previous Behavioral Health Provider(s)
Provider Name:
Office Name:
City/State:
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Provider Name:
Office Name:
City/State:
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Other Current Medical Providers
Cardiovascular/Vascular
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Neurology
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Pain Management
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Endocrinology
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Other:
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Other:
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Other:
Physician Name:
City/State:
Phone:
Format: (000) 000-0000.
Current Medication List
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Medication Name:
Strength per pill:
Number of pills taken at one time?
Number of doses each day?
Personal Medical History (Not family history)
Check any that apply
Heart attack
Other heart disease
High blood pressure
Asthma
Other lung problems
Seizure disorder
Migraine
Stroke
TMJ
Glaucoma
Thyroid problem
Cancer
Bleeding disorder
Blood transfusion
Depression/Anxiety
Suicide attempt
Alcoholism
Hepatitis
Other liver problems
Kidney stone
Other kidney problem
Stomach ulcer
Colon problems
Gout
Arthritis
High cholesterol
Learning disability
Mental disability
Physical disability
Diabetes
Family Medical History
Father Medical History: Check any that apply
Stroke/HeartAttack
High blood pressure
High cholesterol
Thyroid disorder
Asthma
Cancer
Unipolar or bipolar depression
Anxiety/OCD
Psychosis
Learning or cognitive disability
Previous inpatient psychiatric admissions
Previous suicide attempts
Other
Mother Medical History: Check any that apply
Stroke/HeartAttack
High blood pressure
High cholesterol
Thyroid disorder
Asthma
Cancer
Unipolar or bipolar depression
Anxiety/OCD
Psychosis
Learning or cognitive disability
Previous inpatient psychiatric admissions
Previous suicide attempts
Other
Brother(s) Medical History: Check any that apply
Stroke/HeartAttack
High blood pressure
High cholesterol
Thyroid disorder
Asthma
Cancer
Unipolar or bipolar depression
Anxiety/OCD
Psychosis
Learning or cognitive disability
Previous inpatient psychiatric admissions
Previous suicide attempts
Other
Sister(s) Medical History: Check any that apply
Stroke/HeartAttack
High blood pressure
High cholesterol
Thyroid disorder
Asthma
Cancer
Unipolar or bipolar depression
Anxiety/OCD
Psychosis
Learning or cognitive disability
Previous inpatient psychiatric admissions
Previous suicide attempts
Other
Daughter(s) Medical History: Check any that apply
Stroke/HeartAttack
High blood pressure
High cholesterol
Thyroid disorder
Asthma
Cancer
Unipolar or bipolar depression
Anxiety/OCD
Psychosis
Learning or cognitive disability
Previous inpatient psychiatric admissions
Previous suicide attempts
Other
Son(s) Medical History: Check any that apply
Stroke/HeartAttack
High blood pressure
High cholesterol
Thyroid disorder
Asthma
Cancer
Unipolar or bipolar depression
Anxiety/OCD
Psychosis
Learning or cognitive disability
Previous inpatient psychiatric admissions
Previous suicide attempts
Other
Surgical History
Tonsils Date
-
Month
-
Day
Year
Date
Wisdom Teeth Date
-
Month
-
Day
Year
Date
Gallbladder Date
-
Month
-
Day
Year
Date
Appendix Date
-
Month
-
Day
Year
Date
List other Surgeries and Date:
Social History
Do you use tobacco?
Yes
No
Quit Date:
-
Month
-
Day
Year
Date
If you smoke, how many packs per day?
For how long?
Type:
Cigars
Cigarettes
Chew/Snuff
Vape/e-cigarette
Do you drink alcohol?
Yes
No
Number per week?
Is alcohol a concern to you or others?
Yes
No
Do you use recreational drugs?
Yes
No
If yes, type:
Have you used needles?
Yes
No
Caffeine intake?
None
Coffee
Tea
Soda
Indicate daily amount for each checked:
Are there others in your family or support system who should be informed and consulted regarding your pills, or following doctor’s instructions? If yes, who are they and what is their relationship to you?
Do you have enough money to buy the things you need to live everyday such as food, clothing, housing and/or utilities?
Almost always
Most of the time
Some of the time
Never
Are you currently employed?
Yes
No
If so, what is your occupation?
Additional Information
If there is any additional information you wish your provider to know, please note that below:
Submit
Should be Empty: