Supplemental Intake Form (Individual)
First Name*
Last Name*
Date of Birth*
Email Address*
Have they ever had a suicide attempt or been psychiatrically hospitalized?
Yes
No
PSYCHIATRIC/MENTAL HEALTH HISTORY
Psychiatric Hospitalizations:
Add Hospitalization
Have you ever had Psychotherapy?
Yes
No
Have you ever had TMS therapy?
Yes
No
Have you ever had ECT?
Yes
No
MEDICAL HISTORY
Please list all Psychiatric Hospitalizations if any:
Add Hospitalization
Please list all surgical/Medical history if any:
Add Surgery
Do you now or ever had the following conditions? Please select all that apply.
Anemia
Crohn's Disease
Goiter
HIV/AIDS
Pneumonia
Stones
Cataracts
Epilepsy(seizures)
High Blood Pressure
Kidney Disease
Rheumatic
Asthma
Embolism
Heart Problems
Jaundice
Psoriasis
Tuberculosis
Cancer
Emphysema
Hepatitis
Kidney
Pulmonary
Angina
Diabetes
Heart murmur
Hypothyroidism
Pressure
Stroke
Colitis
Fever
High Cholesterol
Leukemia
Stomach or Peptic Ulcer
Other Medical Conditions:
Allergies:
Add Allergy
MEDICATIONS
Current and Past Medications:
Add Medication
SUBSTANCE USE
Substance Use History:
Add Substance
FOR WOMEN ONLY- REPRODUCTIVE HISTORY
Have you reached menopause?
Yes
No
Do you have regular periods?
Yes
No
REVIEW OF SYSTEMS
In the past month, have you had any of the following problems?
NERVOUS SYSTEM
Dizziness
Memory loss
Fainting or loss of consciousness
Numbness or tingling
Headaches
PSYCHIATRIC SYSTEM
Anxiety
Depression
Difficulty Falling Asleep
Food Cravings
Hallucinations
Paranoia
Racing Thoughts
Sensitivity
Violence towards self
Difficulty Staying Asleep
Frequent Crying
Irritability
Poor Appetite
Rapid Speech
Stress
Violence Towards Others
Difficulties with Sexual Arousal
Excessive Worries
Guilty Thoughts
Mood Swings
Poor Concentration
Risky Behavior
Thoughts of Suicides/ Attempts
Access to Gun
Additional Symptoms
GENERAL
Fatigue
Fever
Night Sweats
Recent Weight Gain
Recent Weight Loss
Weakness
THROAT
Difficulty in Swallowing
Frequent Sore Throats
Hoarseness
Pain in Jaw
SKIN
Color changes of Hands or Feet
Hair Loss
Nodules/Bumps
Rash
Redness
MUSCLE/JOINTS/BONES
Numbness
Muscle Weakness
Joint Swelling
Joint Pain
HEART AND LUNGS
Chest Pain
Cough
Fainting
Palpitations
Shortness of Breath
Swollen legs or feet
BLOOD
Anemia
Clots
EARS
Ringing in ears
Loss of Hearing
KIDNEY/URINE/BLADDER
Blood in Urine
Frequent or painful urination
STOMOCH AND INTESTINES
Black Stools
Blood in Stools
Heartburn
Increasing Constipation
Nausea
Persistent Diarrhea
Stomach Pain
Vomiting
Yellow Jaundice
EYES
Double or Blurred Vision
Dryness
Loss of Vision
Pain
Redness
WOMEN ONLY
Abnormal Pap Smear
Bleeding between Periods
Irregular periods
PMS
Others(List)
CURRENT VISIT SOCIAL HISTORY
How are your professional/workplace relationships?
How are your finances and career?
How are your grades if you are in school?
How are your personal relationships?
Any other relevant significant social issues that are impacting you?
In your own words describe why you are here today. Please include how you feel about your mental health condition and any other information that is relevant for this visit.
Submit
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