Medication Management Intake Paperwork - Adult
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
.
Month
.
Day
Year
Date
Presenting Concern:
What brings you to treatment at this time?
*
What is/are your goal(s) for treatment?
*
History of Presenting Concern:
Please check any of the following you have experienced in the last 6 months.
*
Increased appetite
Decreased appetite
Trouble concentrating
Difficult sleeping
Excessive sleep
Low Motivation
Isolation from others
Fatigue/low energy
Low self-esteem
Depressed mood
Tearful or crying spells
Anxiety
Fear
Hopelessness
Panic
Other
Does you currently see a therapist?
*
Yes
No
If so, please include the therapist's name and contact information.
Specify all medications and/or supplements you are presently taking, for what reason and who the prescribing MD is (name, address and phone number).
*
Specify all psychiatric medications you have previously tried and why they were discontinued.
*
Who is your primary care physician? Please include the type of MD, name and phone number.
*
Do you drink alcohol?
*
Yes
No
Do you use recreational drugs?
*
Yes
No
Do you have suicidal thoughts?
*
Yes
No
Have you ever attempted suicide?
*
Yes
No
Do you have thoughts or urges to harm yourself or others?
*
Yes
No
Have you ever been hospitalized for a psychiatric need?
*
Yes
No
If yes, please include when and where.
Family of Origin Information:
Describe your current living situation:
*
Is there a history of mental illness in your family?
*
Yes
No
If yes, please specify as comfortable.
Is there a history of trauma?
*
Yes
No
If yes, please specify as comfortable.
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