Psychiatric intake form

One Vanderbilt Park Drive, Suite 115, Asheville, NC 28803 (828) 274-2221 • • Fax (828)274-2226 ____________________________________________________________________________________________________________________ Date of first appointment _______________________
Name______________________________________ Date of Birth_________________
List the problems for which you want to be seen today: ___________________________
During your lifetime, when did these problems first start? __________ How long have
they been bothering you currently? ________________ How do they keep you from
functioning at home or work? _______________________________________________
How do they affect relationships with family, friends or people at work? _____________
____________________________ What are your current stressors? _________________
Treatment History
If you have a history of outpatient mental health care or hospitalizations, please complete
the following:
Diagnosis / Problem Dates treated Where / By whom?
Are you currently receiving psychotherapy or any professional counseling? ( ) y ( ) n
If yes, from whom? _________________________________ Phone_____________

Medication History
Fill in information on any medication you have taken or are currently taking now.
Dates Dosage
Response/Side effects
Anafranil (clomipramine)_________________________________________________________ Celexa (citalopram)______________________________________________________________ Cymbalta (duloxetine)____________________________________________________________ Desyrel (trazodone)______________________________________________________________ Effexor (venlafaxine)____________________________________________________________ Elavil (amitriptyline)_____________________________________________________________ Lexapro (escitalopram)___________________________________________________________ Luvox (fluvoxamine)_____________________________________________________________ Pamelor (nortrptyline)____________________________________________________________ Paxil (paroxetine)________________________________________________________________ Pristiq (desvenlafaxine) __________________________________________________________ Prozac (fluoxetine)______________________________________________________________ Remeron (mirtazapine)___________________________________________________________ Serzone (nefazodone)____________________________________________________________ Tofranil (imipramine)____________________________________________________________ Wellbutrin (bupropion)___________________________________________________________ Zoloft (sertraline) _______________________________________________________________ Depakote (Valproate)___________________________________________________________ Lamictal (lamotrigine)___________________________________________________________ Lithium (lithium carbonate) _______________________________________________________ Tegretol (carbamazepine)_________________________________________________________ Abilify (aripiprazole) ____________________________________________________________ Clozaril (clozapine)______________________________________________________________ Geodon (ziprasidone)_____________________________________________________________ Haldol (haloperidol)______________________________________________________________ Prolixin (fluphenazine)___________________________________________________________ Seroquel (quetiapine)_____________________________________________________________ Zyprexa (olanzepine)_____________________________________________________________ Ativan (lorazepam)______________________________________________________________ Klonopin (clonazepam)___________________________________________________________ Restoril (temazepam)_____________________________________________________________ Valium (diazepam)_______________________________________________________________ Xanax (alprazolam)______________________________________________________________ Ambien (zolpidem)______________________________________________________________ Lunesta (eszopiclone)____________________________________________________________ Sonata (zaleplon) _______________________________________________________________ Adderall (amphetamine)__________________________________________________________ Concerta (methylphenidate)_______________________________________________________ Ritalin (methylphenidate)_________________________________________________________ Strattera (atomoxetine)____________________________________________________________ Other _________________________________________________________________________ Family Psychiatric History:
Has any genetically-related family member been diagnosed with, or treated for, the
following problems? Indicate the relationship the family member has to you on the line.
Bipolar disorder

What is your highest educational level attained?_________________________________
Do you have current plans to further your education? _____________________________
Are you currently: Employed Unemployed Student Retired Disabled
What is/was your occupation? _______________________________________________ Do you have work-related stressors that affect your well-being? ____________________
Marital History and Current Family:
How would you describe the quality of your relationship with your spouse/partner? (e.g. supportive, strained) ______________________________________________________ Do you have children? ______ Ages: ___________ Stressors? ____________________ How many people currently live in your home? ___ Who else, other than your partner and children, live(s) in your home? __________________________________________ Legal History
Do you have any pending legal problems?_____________________________________
Have you had any significant legal problems in the past that have affected your well-being and functioning (e.g. DWI, loss of parental rights, incarceration)? ______________ Military History
Have you ever served in the military? ______ If so, what branch and when? _________
Trauma History: Do you have a history of trauma from childhood abuse, military
combat, workplace trauma, domestic violence, rape, or medical trauma? ( )y ( )n
Coping Skills
Are there any positive skills or tools that you use to help you feel better when distressed
(e.g., spiritual beliefs, talking to friends, exercise)? __________________________
Is there anything you do, when distressed, that could harm you or is unhelpful (e.g.,
abusing substances, driving unsafely, harming yourself by cutting or in any other way,
withdrawing from others)? ___________________________________________

Substance Use/Abuse Treatment History

Do you think you may have a problem with alcohol or drug use? ( ) y ( ) n
In the past, or now, have you attended any support groups (e.g., AA or NA)? ( )y ( )n
Have you ever been treated for alcohol or drug abuse? ( ) y ( ) n
If yes, where were you treated and when? ______________________________________

Alcohol History

How many alcoholic drinks do you consume each week? _________________________
In the past 3 months, what are the most alcoholic drinks you have consumed in a day? __
Have you ever felt you should cut down on your drinking or drug use? ( ) y ( ) n
Have people annoyed you by criticizing your drinking or drug use? ( ) y ( ) n
Have you ever felt bad or guilty about your drinking or drug use? ( ) y ( ) n
Have you ever had a drink or used drugs first thing in the morning to steady your nerves
or to get rid of a hangover? ( ) y ( ) n
Other Substance Use/Abuse
Have you used any street drugs or medications that were not prescribed to you in the past 3 months? _____________ Check if you have ever used the following: ( ) ( ) ___________________________________ Other __________________________________________________________________ Have you ever overused prescribed pain medication or tranquilizers/sleeping pills? ( )y ( )n How many caffeinated beverages do you drink a day? ____________________________

Tobacco History

Cigarettes: Now? ( ) y ( ) n In the past? ( ) y ( ) n When did you quit? _______ Do you use other tobacco products? ( ) y ( ) n If so, what kind? _________________ If you are currently using tobacco products, have you tried /thought about quitting? ____
Medical History

Current prescription medications and supplements, other than psychiatric medication
indicated above. Indicate dosage, how often and when you take them (if none, write
Current medical problems:____________________________________________________________
Past medical problems, hospitalizations/surgeries and approximate dates ________________

For women only:
Pre-menopausal_____ Menopausal_____ Post-menopausal______
Are you currently pregnant or do you think you might be pregnant? ( ) y ( ) n
Are you planning to get pregnant in the near future? ( ) y ( ) n
Birth control method ______________________________________________________

Do you have a history of:

Heart disease_______________________________ Respiratory problems_________________________ Stomach or intestinal problems _________________ Liver disease________________________________ Kidney disease______________________________ Diabetes____________________________________ Cancer _____________________________________ Epilepsy or seizures_____________________ High cholesterol_____________________________ High blood pressure __________________________

Descibe your exercise pattern (How often? How long? Type?) ____________________________
Diet (Regular meals? Healthy? Vegetarian? Problems with appetite, sugary snacks? etc) _______
Sleep (Too much or too little? Not restful? Difficulty falling or staying asleep?) _______


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