Medical Intake form

Anew Psychiatry Patient Treatment Intake

Please fill out all information to the best of your ability.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Preferred Method of Contact:

PhoneEmailText
Gender*
Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Type of treatment interested in:*
Insurance Information
Insurance Company:*
Subscriber Name:*
Subscriber DOB:*

MonthDayYear
Date
Member ID #:*
Group #:*
I understand*

I am responsible for verifying my insurance benefits and for all charges not covered by insurance.
Psychiatric History
Reason for seeking services (check all that apply):*

DepressionAnxietyADHDBipolar DisorderPTSDPanic AttacksSleep IssuesMood SwingsTraumaMedication ManagementOther
Briefly describe your current concerns:*
Previous mental health treatment?*

YesNo
If yes, please explain (provider, dates, type of treatment):
Past psychiatric hospitalizations?*

YesNo
If yes, please explain:
Have you ever had thoughts of harming yourself?*
Have you ever had thoughts of harming others?*
History of suicide attempts?*
Have you tried any of the following integrative psychiatric treatments?*

TMSECTPsychedelicsKetamine/ EsketamineVagal Nerve StimulatorNoneOther
MEDICATION HISTORY
Please list ALL CURRENT medications you are taking:*
Psychiatric medications currently on or have tried in the past:*
Please list any natural remedies and vitamins, you are currently taking:
Medical History

This questionnaire is an essential part of providing you with the best possible healthcare. Your answers will help us understand any problems you may have. Please answer every question to the best of your ability.
Who is your Current Primary Care Physician?
Do you see any specialty doctors? (cardiologists/neurologists/etc.) List names and location:
Do you have any allergies (including medications)?*

YesNo
If yes, please list.
Have you ever had any serious illness?*
Have you ever undergone surgery?*
Please select all of the following that apply to you*
Have you ever been hospitalized for a medical reason?*
Substance Use

Do you currently or have you ever used any of the following?*

Rows	Never	Occasionally	Frequently	In the past
Alcohol
Cannabis
Opioids
Benzodiazepines (e.g., Xanax):
Cocaine/methamphetamines:
Hallucinogens (e.g., LSD, psilocybin):
Ketamine (outside medical use):
Cigarettes, vapes, tobacco use
Caffeinated Beverages (more than 2)
Coffee (more than 6 cups a day)

If other or any comments...
Social History
Marital Status
Highest degree obtained:
Do you have any children?

YesNo
If so, how many and how old?
Do you currently work or attend school?

YesNo
What is your current occupation, or what are you in school for?
Do you use any assistive devices or have mobility issues?

YesNo
Who is in your support system?
Do you exercise regularly?

YesNo
If yes, how often?
Hobbies and Interests:
Rate your current level of functioning (1 = very poor, 10 = excellent): ___ /10
How many of hours do you sleep per night on average?
How would you describe your usual sleeping habits?
Family History

Does anyone in your family suffer from any psychiatric disorder(s)?

Rows	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
Bipolar Disorder
Manic Depression
Anxiety Disorder
ADHD
Substance Abuse
Schizophrenia
Other

Comments
Should be Empty:

Anew Psychiatry Patient Treatment Intake

Insurance Information

Psychiatric History

MEDICATION HISTORY

Medical History

Substance Use

Social History

Family History