Please review the information you provided before submitting the form
Name
{Patient Name: (Last):26.6}, {Patient Name: (First):26.3}
Address
{Address (Street Address):5.1}
{Address (City):5.3}
{Address (State / Province):5.4}
{Address (ZIP / Postal Code):5.5}
Phone
{Phone:6}
Email
{Email:7}
Date of Birth
{Date of Birth:8}
Gender
{Gender:10}
How did you hear about this practice?
{How did you hear about this practice?:12}
Front of Insurance Card
{Front of Insurance Card:15}
Back of Insurance Card
{Back of Insurance Card:16}
Drivers License
{Drivers License:29}
Credit Card Number
{Credit Card Number:44}
Expiration Date
{Expiration Date:37}
Security Code
{Security Code:38}
Billing Zip Code
{Billing Zip Code:46.5}
I have read the above Agreement and Office Policies carefully; I understand them and agree to comply with them:
Patient Name
{Patient Name: (Last):26.6}, {Patient Name: (First):26.3}
Date
{Date:27}
Patient Health Screen
Please state the reason for making this appointment:
{Please state the reason for making this appointment::18}
What are the most concerning psychiatric symptoms for you?
{What are the most concerning psychiatric symptoms for you?:47}
Have you ever been diagnosed with any psychiatric conditions?
{Have you ever been diagnosed with any psychiatric conditions?:48}
{Please list below:19}
Please list all current prescription medications, over the counter medications and/or supplements you are taking:
{Please list all current prescription medications, over the counter medications and/or supplements you are taking::49:}
Please list past psychiatric medications that you discontinued and for what reason?
{Please list past psychiatric medications that you discontinued and for what reason?:50:}
Please list any allergies to medications:
{Please list any allergies to medications::21}
Please list all current medical problems:
{Please list all current medical problems::22}
Please list any past medical problems and major surgeries:
{Please list any past medical problems and major surgeries::23}
Preferred Pharmacy
{Preferred Pharmacy:92:}
Please tell us about your current/past providers:
Do you have a primary care provider?
{Do you have a primary care provider?:54}
{:55:}
Have you ever seen a psychiatrist before?
{Have you ever seen a psychiatrist before?:56}
{:57:}
Are you currently seeing a therapist?
{Are you currently seeing a therapist?:59}
{:58:}
Were you ever hospitalized for a psychiatric condition?
{Were you ever hospitalized for a psychiatric condition?:60}
{:61:}
Are you currently dealing with significant financial problems (bankruptcy, foreclosure, large debt, etc.)?
{Are you currently dealing with significant financial problems (bankruptcy, foreclosure, large debt, etc.)?:62}
{Please list below:63}
Are you currently dealing with significant legal problems (custody issues, divorce, DUIs, etc.)?
{Are you currently dealing with significant legal problems (custody issues, divorce, DUIs, etc.) ?:64}
{Please list below:65}
Please tell us more about yourself:
Education Level:
{Education Level::95}
Employment:
{Employment::94}
Relationship:
{Relationship::96}
Do you have Children?
{Do you have Children?:70}
{How many?:72}
Where were you born and raised?
{Where were you born and raised?:73}
Please list everyone who currently lives with you:
{Please list everyone who currently lives with you::74}
Please list your use of:
Alcohol
{Alcohol:76:}
Marijuana
{Marijuana:77:}
Cocaine
{Cocaine:78:}
Heroin
{Heroin:79:}
Methamphetamine
{Methamphetamine:80:}
LSD/Hallucinogen
{LSD/Hallucinogen:81:}
Pain Killers
{Pain Killers:82:}
Sleeping Pills
{Sleeping Pills:83:}
Cigarettes/Tobacco
{Cigarettes/Tobacco:84:}
Have you ever been treated for drug or alcohol abuse?
{Have you ever been treated for drug or alcohol abuse?:85}
{Please list below:86}
Are there any medical problems that run in your family? If yes, please list disease(s) and your relationship:
{Are there any medical problems that run in your family? If yes, please list disease(s) and your relationship::87}
Are there any psychiatric problems that run in your family? If yes, please list disease(s) and your relationship:
{Are there any psychiatric problems that run in your family? If yes, please list disease(s) and your relationship::88}
Please list any other information you think is important for the provider to know:
{Please list any other information you think is important for the provider to know::89}
