Cool Springs Psychiatric Group
Patient Name ________________________________ Date of Birth___________ Date form completed: _________________________ *Please arrive on time and bring this form completed to your appointment to avoidany delay in seeing the doctor* 1. What is prompting you to seek help? What do you want to change?_________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________ 2. Why are you here now at this time in your life?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. What is troubling you the most? (Please describe in detail)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. What makes your problems/symptoms better?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5. What makes your problems/symptoms worse?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PSYCHIATRIC HISTORY6. Are you currently seeing a therapist? (Name & contact phone#)_______________________________________________________________________________________________________ 7. Have you ever seen a psychiatrist, psychotherapist, marriage counselor or familytherapist for outpatient treatment? (List approximate duration of therapy and your age at that time)?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Page 2Patient Name:__________________________________________ 8. Previous history: Have you ever been treated for any of the following (circle all that apply).
Depression ADD/ADHD Bipolar (Manic/Depressive) DisorderAnxiety OCD Schizophrenia Panic Attacks PhobiasAlcohol Problems (including AA) Anorexia/Bulimia Binge-eating PTSDSocial Anxiety Drug Problems ECT treatment 9. Please list in chronological order all prior psychiatric hospitalizations (if any) below: None Approximate Date
Length of Stay
Name of Hospital
Reason for Admission
10. Have you ever attempted to harm/kill yourself? If so, please list the occurrences below: Never
Approximate date of attempt
How did you attempt (method)
11. Prior drug related problems (circle all that apply): others:______________________________________ 12. How much tobacco do you use now? _____________________________________________ 13. Prior suicidal, dangerous and impulsive/compulsive behavior (check all that apply): _____ hallucinations commanding suicide_____ self-injurious behavior, i.e., cutting, burning_____ harm to others_____ gambling problems_____ impulsive/compulsive shopping_____ impulsive/compulsive sexual behavior 14. Prior alcohol related problems (check all that apply): _____ever felt or been told you drink too much?_____ ever drink or use first thing in the morning?_____ ever experience alcohol or drug withdrawal?_____ever gone through alcohol/drug detoxification?_____ever been in an alcohol or drug rehabilitation program? Page 3Patient Name___________________________________________ 15. Review the following list of medications. If you have taken any of these medications prescribedby any healthcare provider, please fill out the specific boxes related to that medication.
Did it help
Any Side effects?
Selective Serotonin Reuptake Inhabitors (SSRIs)
Serotonin-Norepinephrine Reuptake Inhabitors (SNRIs)
Other Antidepressants
Tricyclic Antiodepressants
Other Psychotropics (Have you taken any of these?) Please circle
Page 4Patient Name:____________________________________________________ SOCIAL HISTORY
16. Race/Ethnicity (check one or more):
18. If you are married or cohabitating with partner, how long has this been? _____Yrs. _______Mos.
19. Total number of marriages: ________ Your age when married______ 20. How many children do you have? _______ 21. Females Only: Your age when your children were born?_________________________________ Did you ever experience post-partum problems (treated or untreated)?________ If yes, what was your age?________Are you pregnant or plan to become pregnant with the next 6 months?_______ 22. Spouse's/Partner's Name:__________________________________________________________ 23. Who else lives with you?___________________________________________________________ 24. How many years of formal education have you completed? _______ years 25. Highest degree obtained: (check only one) ___High school graduate ___G.E.D. ___4 year college degree ___MBA/MA/MS/MPH___M.D. ___Junior college degree or technical school diploma ___JD/LLB___Ph.D ___Other____________________________ 26. What best describes your current employment status? (check one from each category a,b & c_) a. Employment Status
b. Student
c. Volunteer Status
__Part-time employed__On welfare __Social security disability 27. What is your occupation?_____________________________ Employer:___________________ How long have you been employed there?___________ 28. What is your spouse's occupation?__________________________________________________ 29. Current Residence: __own home/condo __Retirement/Senior housing __Renting Page 5Patient Name:___________________________________________30. Family History: Has anyone in your family ever been treated for any of the following: (please check all that apply and when appropriate indicate paternal or maternal) DepressionAnxietyPanic AttacksPost Traumatic StressBipolar/Manic depressionSchizophreniaAlcohol ProblemsDrug ProblemsADHDSuicide attemptsSuicide completedPsychiatric hospital stay 31. Medical History: Do you have or have you ever had any of the following (please check all that
apply)? Please write in your medical problems in each category.
___High Blood Pressure
___Gastrointestinal Problems (ulcers,pancreatitis, ___Neurological Problems (stroke, brain tumor ___Viral Illness (herpes, Epstein-Barr, ChronicHepatitis) Page 6Patient Name:__________________________________________________ 31. Please List ALL current medications below (include birth control pills, over the counter medicationand herbal remedies (i.e. decongestants, St. John's Wort, etc.) 32. Who is your primary care physician? ______________________________________________ 33. List any drug allergies: _________________________________________________________ 34. Current/recent stresses (check all that apply with a brief explanation):___Break up of relationship:__________________________________________________________ ___Serious argument: ______________________________________________________________ ___Child/other left home: ____________________________________________________________ ___Death of spouse/other: ___________________________________________________________ ___Health of family member: _________________________________________________________ ___Behavior of family member: ________________________________________________________ ___Personal injury of illness: __________________________________________________________ ___Retired: ________________________________________________________________________ ___Loss of job: _____________________________________________________________________ ___Change of residence: _____________________________________________________________ ___Legal difficulty: __________________________________________________________________ ___Financial problems: ______________________________________________________________ ___Other: _________________________________________________________________________ Page 7Patient Name: ________________________________________________________ 35. Has there ever been a period of time when you were not your usual self? Check all that apply: a. ___ you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?b. ___you were so irritable that you shouted at people or started fights or arguments?c. ___you felt much more self-confident than usual?d. ___you got much less sleep than usual and found you did not really miss it?e. ___you were much more talkative or spoke much faster than usual?f. ___thoughts raced through your head or you could not slow your mind down?g. ___you were so easily distracted by things around you that you had trouble concentrating or staying on track?h. ___you had much more energy than usual?i. ___you were much more active or did many more things than usual?j. ___you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?k. ___you were much more interested in sex than usual?l. ___you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?m. ___spending money got you or your family into trouble? 36. If you checked more than one of the above, have several of these ever happened during the same period of time? 37. How much of a problem did any of these cause you -- being unable to work; having family; money, or legal troubles; getting into arguments or fights? Please circle one (1) response only: No problem Minor problem Moderate problem Serious problem 38. Has a health professional ever told you that you have manic-depressive illness, bipolar disorder, adult ADD or ADHD? ____________________________________________________________ 39. Are you on a diet of any kind? ______ If yes, explain: ___________________________________________________________________________________________________________________ 40. When do you typically go to bed? __________________________________________________ 41. What are your weekly patterns of exercise? _____________________________________________________________________________________________________________________________ 42. List a few positive changes you would like to see in yourself over the next few months:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.cspsychiatric.com/NyquistHistory1-7.pdf


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