Initial Evaluation

Name

First NameLast Name

Date of Birth

MonthDayYear

Cell Phone Number

Country CodeArea CodePhone Number

Email

example@example.com

Legal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pharmacy (name, address, phone number)

Medication Requested or Considered (name, dose, frequency)

Medical History

Rows	Diagnosis / Issue
Problem #1
Problem #2
Problem #3
Problem #4

Treatment (as it relates to the medical history above)

Rows	On Medication?	Under Control?
Problem #1
Problem #2
Problem #3
Problem #4

Medication History - name, dose, frequency

If you are currently taking any medications for non-mental health issues

Mental Health History

Rows	Diagnosis / Issue
Problem #1
Problem #2
Problem #3
Problem #4

Treatment (as it relates to the mental health history above)

Rows	On Medication?	Under Control?
Problem #1
Problem #2
Problem #3
Problem #4

Medication History - Past & present psychoactive medications

Rows	Medication name, dose, frequency
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6

Medication Effectiveness (as it relates to the above list)

Rows	Effective?	Side Effects?	Still Taking?
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6

Allergies to Medications (name, reaction)

Medication Side Effects

Other Medications, Treatments, Interventions

Health Screening - In the last 3 months, have you:

Rows	No	Yes	N/A
Become pregnant or started breastfeeding?
Received any health care services from a provider, clinic, urgent care, or ER?
Developed new symptoms or health issues?
Sustained falls or other injuries?
Undergone new laboratory and/or diagnostic testing?
Taken pain medications or antibiotics?
Engaged in excessive drinking or any other risky behavior?
Started new medications or stopped taking any of your medications?
Developed new allergies to medications?
Taken or stopped taking any street drugs?
Had to borrow medications from your family and/or friends?
Had changes in family situation?
Experienced significant life/family/relationship stresses?
Had thoughts of hurting yourself or others?

Review of Systems - How you are feeling now:

Rows	No	Yes
Fever, chills, night sweat, weight loss
Sore throat, runny nose
Weakness, poor vision, loss of hearing
Cough, phlegm, shortness of breath, wheezing
Chest pain, palpitations, leg swelling
Stomach issues, poor appetite
Urinary problems
Abnormal periods, bleeding
Headache, neck pain, back pain, joint pain
Dizziness, numbness, fainting
Memory loss, depression, anxiety, irritability, mood swings, cravings, insomnia
Bruising, blood clots
Rashes, wounds, hair loss

Other New Health Issues

Treatment Regimen:

Rows	Yes	No	N/A
Since your last visit with a mental health provider, have you been feeling better?
Is the current medical regimen working?
Is it helping you with your mood?
Is it helping you with your sleep?
Is it helping you with your energy level?
Is it helping you with your sleep?
Is it helping you with your work/school performance?
Is it helping you with your interpersonal relationships?
Do you feel you are taking too much medication?
Should we try a different approach?
Do your family/friends express concern about your health/treatment?
Do you need a referral to a specialist?

Are you seeing a therapist?

CONSENT FOR TREATMENT

Services
I am requesting medical/mental health services.

Self-Payment
I am fully aware that I am fully responsible for all charges regardless of the health coverage. I further agree not to submit a claim or ask Provider to submit a claim to Medicare/Medicaid.

Full Disclosure
I agree to provide Provider with the accurate and updated information regarding my condition, past illnesses, possible pregnancy or intention to get pregnant (women), prescription and non-prescription medications taken, allergies to medications, and other matters that may affect diagnosis and treatment. If I become aware of any changes in this information, I will notify Provider during the subsequent visits.

Electronic Communications
We rely heavily on electronic communication. You agree that all agreements, test results and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.

Courtesy
While we make every effort to provide prompt on-time service, medicine hardly lends itself to an exact schedule. We appreciate your understanding and patience.

:AM/PM Option

INITIAL EVALUATION