New Patient Psychiatric Questionnaire
Patients Name
Nickname
Age
Sex
Male
Female
Other
Self Identified Race
Date
-
Month
-
Day
Year
Date
Chief Complaint
1. Please list the reasons you have sought a psychiatric consultation at this time?
2. Sleep: My sleep is normal
Yes
No
If not normal, check problem; I have trouble:
falling asleep
staying asleep
waking up too early
sleeping too much
3. Energy: (select one) My energy is normal;
too low
too high
4. Appetite: (select one) My appetite is
normal
decreased
increased
Have you lost or gained weight recently?
Yes
No
If so, how much?
5. Have you ever become desperate enough to consider:
Yes
No
Death?
Hurting yourself?
Suicide?
Hurting someone?
Homicide?
Divorce?
Destroying something?
Running away?
Doing something crazy?
Using Drugs?
6. How were you referred to Dr. Drell?
7. May we thank and/or share information with you referral source?
Yes
No
If Yes, please place your initials here
Past Psychiatric History
8. Have you seen any other psychiatrists or therapists prior to this appointment?
Yes
No
If yes, please list their names and addresses, and whether or not give us permission to request information and records from the physician/therapist if necessary.
9. Have you ever been hospitalized for psychiatric problems, alcohol, or substance abuse? If so, please fill out the following?
10. Have you taken any psychiatric medications in the past? These might include the following: Elavil, Doxepin, Pamelor, imipramine, Prozac, Zoloft, Paxil, Lexapro, Celexa, Luvox, Serzone, Ativan, Klonopin, Librium, Haldol, Navane, Thorazine, Mellaril, Zyprexa, Risperadal, Seroquel, Geodon, Abilify, Lamictal, Tegretol, Topamax, Depakote, etc. if so, please list them below.
Medical History
11. Who is your primary medical doctor?
Address
Date last seen
Do you give permission for us to discuss your case with your primary medical doctor if clinically necessary?
Yes
No
Initial here please
12. Do you have any current health problems? Please list
13. Please write your height
Weight
Ideal Weight
Waist size in inches (as a baseline for medication related weight change)
14. Do you have a family history of Diabetes, Heart Disease, sudden death, prolongedQT Syndrome, Cardiomyopathy, thyroid problems, ETC. ?
15. Are you currently on any medications?
Yes
No
If yes, please list them below:
Medication
Dosage
Directions
1
2
3
4
5
6
7
8
16. Are you taking any vitamins, herbal products, dietary supplements, alternativemedications or weight loss preparations? Please list them below:
17. Are you allergic to any medications? If yes, please list:
18. Have you had any surgeries in the past? If so, please list the type of surgery and date:
19. Do you suffer from chest pain, shortness of breath, palpitations, or dizziness on exertion?
Yes
No
20. Have you ever fainted or almost fainted (especially without exercising)?
Yes
No
21. Gave you had any head injuries, loss of consciousness or seizure disorders?
Yes
No
22. Do you have tics, facial twitches, or tremors?
Yes
No
Do you have a family history of these?
Yes
No
23. Do you have a history of glaucoma?
Yes
No
23. Do you have a history of glaucoma?
Yes
No
Is it being treated?
24. Do you have a pacemaker, implantable pumps or metal appliances?
Yes
No
25. Do you obsess on food, overeat compulsively, restrict what you eat, or vomit (purge) intentionally?
Yes
No
26. Are you pregnant or do you plan to get pregnant soon?
Yes
No
When was your last menstrual period?
Family Psychiatric History
Has anyone in your family had emotional or psychiatric problems, drug/ alcohol abuse problems, or suicide? (include grandparents, aunts, uncles, parents, siblings, child- ren or spouse). Please list and explain what problems and treatments they have received
Social History
28. Please list the name and age of your parents, spouse, children, siblings, and significant other, as well as their occupations.
Relative/age emotional problems
Specific drug/alcohol or received
Treatment received
Mother
Father
Siblings
Spouse/significant
Childrens
29. Did your parents ever divorce or separate?
Yes
No
If yes, how old were you?
Who did you live with?
30. Where were you born and raised?
31. Have you been a victim of physical, sexual, or emotional Abuse?
Yes
No
If so, by whom?
Has anyone at home hit or harmed you?
Yes
No
Do you feel safe at home?
Yes
No
32. Were either of your parents sexually or physically abused or did your mothersuffer from ptsd (post traumatic stress disorder)?
Yes
No
33. Have there been any significant stressors in the last 12 months (debt, divorce,illness, moves, etc.)?
34. Who currently lives in your household?
35. Do you consider yourself Heterosexual
Heterosexual
Homosexual
Bi -sexual
36. How many times have you been:
Married?
Divorced?
Separated?
Widowed?
37. What was your longest marriage?
38. When were you growing up, did you have a normal development (walk ontime/talk on time, etc.)?
39, What is your highest educational level of completed education?
40. Where do you work or go to school?
41. How long have you been at your current job?
42. How long was your longest job?
43. Were you in the military?
If so, when and which branch?
44. Do you currently have any stressors related to finances?
45. Do you have any legal problems?
46. What is your religious preference?
Are you actively involved?
47. What are your hobbies? What do you do for FUN?
48. Drug/Alcohol and Tobacco History
Substance
Amount
Frequency
Duration
1st use
Last use
Caffeine
Tobacco
Alcohol
Marijuana
Opiates /narcotics
Amphetamines
Cocaine
Hallucinogens
Synthetic drugs/bath salts/incense
OTHERS
49. Select 'Yes' or 'No'
Yes
No
Do you drink alcohol in the morning?
Have you ever had a DWI or public intoxication charge?
Do you feel you are a normal drinker or non drinker currently?
Was there a time in the past when you felt you used alcohol or drugs excessively?
Do friends/relatives think you're a normal drinker or non-drinker?
Have you ever lost friends or girl/boyfriends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have you ever neglected your obligations, family, or your work for 2 or more days in a row because of your drinking?
Have you ever had delirium tremens (DTs), severe shaking, hearing voices, or seen things that weren't there after heavy drinking?
Have you ever gone to anyone for help for your drinking or drug usage?
Have you ever been in a hospital because of drinking or drug usage?
Have family or friends ever expressed concern over your use of drugs?
Have you ever been arrested for any offense involving drugs?
Have you ever been treated for chemical dependency?
Have you overdosed on drugs (accidentally or on purpose) ?
Have you ever attended a 12 step meeting (AA, NA CA, ALANON, etc.)
Yes
NO
IF yes, which ones?
50. Select 'Yes' or 'No'
Yes
No
A. Do you often have trouble wrapping up the final details of a project once the challenging part is done?
B. Do you often have difficulty getting things in order when you have to do a task that requires organization?
C. Do you often have problems remembering appointments or obligations?
D. Do you often procrastinate getting started when a task requires a lot of thought?
E. Do you often feel restless with your hands or feet when you have to sit down for a long time?
F. Do you often feel restless or overly active and compelled to do things like you were driven by a motor?
Miscellaneous
51. Do you have any intrusive, unwanted or repetitive thoughts that you cannot control (obsessions)?
Yes
No
52. Do you wash your hands excessively or repeatedly check things (compulsive behaviors)?
Yes
No
53. Do you do needless counting or repeating?
Yes
No
54. Do you have a history of:
Promiscuity?
Compulsive spending?
Reckless driving?
Gambling?
55. Do you own a handgun?
Yes
No
When did you purchase/obtain it?
56. Do you agree with the following statements?
Yes
No
Suicide is a normal behavior.
Sometimes suicide is the only escape from life's problems.
In general, suicide is an evil act not to be condoned.
I have a religious/moral prohibition of suicide.
57. Please list your strengths (E.G. positive personality traits, talents, what is good about you?):
58. Please list your weaknesses or limitations:
59. Please list any personal changes you would like to make:
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: