One Vanderbilt Park Drive, Suite 115, Asheville, NC 28803
(828) 274-2221 • www.AshevillePsych.net • Fax (828)274-2226
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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
Education What is your highest educational level attained?_________________________________
Do you have current plans to further your education? _____________________________ Occupation 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
Allergies________________________________________________________________ Current prescription medications and supplements, other than psychiatric medication indicated above. Indicate dosage, how often and when you take them (if none, write none).__________________________________________________________________ _____________________________________________________________ _____________________________________________________________ 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 __________________________
Habits 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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Family Psychiatric History: