roswellpsychiatry.com - Mental Health Intake Form

Roswell Psychiatry Clinical Intake Form
Name:
Date of Birth:

MonthDayYear
Date
Complaint
What is your major complaint?
Have you previously suffered from this complaint and when did it start?
Previous therapist or Psychiatrist:
Previous treatment for complain:
Current Symptoms (Check all that apply)

AnxietyAppetite IssuesSuspiciousnessDepressionExcessive EnergyAvoidanceHallucinationsImpulsivityIrritabilityLoss of interestPanic AttacksFatigueSleep ChangesRacing thoughtsRisky ActivityCryingGuiltLibido Changes
Medical History
Allergies:
What medications are you currently taking:
Previous diagnoses/ mental health treatment:
Previous medications:
Previous medical conditions:
Previous surgeries:
Any History of mental health conditions in your family? If so, who and what conditions:
Drug or Alcohol History:
Rehab or dextox History:
Have you been recently discharged from any PHP or inpatient program:
Should be Empty:

Roswell Psychiatry Clinical Intake Form