Patient History Form



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Patient History Form




Date: _______/_________/________

NAME:










Birthdate: _____/______/_____




Last

First

M. I.




Age:___________ Sex:  F  M













How did you hear about this clinic?










Describe briefly your present symptoms:










Please list the names of other practitioners you have seen for this problem:










Psychiatric Hospitalizations (include where, when, & for what reason):










Have you ever had ECT? Have you had psychotherapy?




CURRENT MEDICATIONS

Drug allergies:  No  Yes To what?




Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

Name of drug

Dose (include strength & number of pills per day) How long have you been taking this?

1.




2.




3.




4.




5.




6.




7.




8.




9.




10.




11.




12.






Past medical history

Do you now or have you ever had:
















 Diabetes

 Heart murmur

 Crohn’s disease

High blood pressure

 Pneumonia

 Colitis

 High cholesterol

 Pulmonary embolism

 Anemia

 Hypothyroidism

 Asthma

Jaundice

 Goiter

 Emphysema

 Hepatitis

 Cancer (type) _________________

 Stroke

 Stomach or peptic ulcer

 Leukemia

 Epilepsy (seizures)

 Rheumatic fever

 Psoriasis

Cataracts

 Tuberculosis

 Angina

 Kidney disease

 HIV/AIDS

 Heart problems

 Kidney stones










Other medical conditions (please list):



















PERSONAL HISTORY

Were there problems with your birth? (specify)




Where were your born & raised?




What is your highest education?

High school Some college College graduate Advanced degree

Marital status:  Never married  Married  Divorced  Separated  Widowed  Partnered/significant other

What is your current or past occupation?




Are you currently working? :  Yes  No

Hours/week ______

If not, are you  retired  disabled  sick leave?

Do you receive disability or SSI?  Yes  No

If yes, for what disability & how long?___________________________

Have you ever had legal problems? (specify)




Religion:







FAMILY HISTORY

If living

If deceased




Age (s)

Health & Psychiatric

Age(s) at death

Cause

Father













Mother













Siblings











Children











EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal Relatives:




Paternal Relatives:









Systems Review




In the past month, have you had any of the following problems?










General

NERVOUS SYSTEM

PSYCHIATRIC

 Recent weight gain; how much____

 Headaches

 Depression

 Recent weight loss: how much____

Dizziness

 Excessive worries

 Fatigue

 Fainting or loss of consciousness

 Difficulty falling asleep

 Weakness

 Numbness or tingling

Difficulty staying asleep

 Fever

 Memory loss

 Difficulties with sexual arousal

 Night sweats




 Poor appetite







 Food cravings

Muscle/Joints/Bones

STOMACH AND INTESTINES

Frequent crying

 Numbness

 Nausea

 Sensitivity

 Joint pain

 Heartburn

 Thoughts of suicide / attempts

Muscle weakness

 Stomach pain

 Stress

 Joint swelling

 Vomiting

 Irritability

Where?

 Yellow jaundice

Poor concentration




 Increasing constipation

 Racing thoughts

EARS

 Persistent diarrhea

 Hallucinations

 Ringing in ears

Blood in stools

 Rapid speech

 Loss of hearing

 Black stools

 Guilty thoughts







 Paranoia

EYES

SKIN

Mood swings

 Pain

 Redness

 Anxiety

 Redness

 Rash

 Risky behavior

 Loss of vision

 Nodules/bumps




Double or blurred vision

 Hair loss




 Dryness

 Color changes of hands or feet

OTHER PROBLEMS:










THROAT

BLOOD




 Frequent sore throats

 Anemia




 Hoarseness

 Clots




Difficulty in swallowing







 Pain in jaw

KIDNEY/URINE/BLADDER







 Frequent or painful urination




HEART AND LUNGS

 Blood in urine




 Chest pain







 Palpitations

Women Only:




Shortness of breath

 Abnormal Pap smear




 Fainting

 Irregular periods




 Swollen legs or feet

 Bleeding between periods




 Cough

 PMS













WOMENS REPRODUCTIVE HISTORY:

Age of first period:

# Pregnancies:

# Miscarriages:

# Abortions:

Have you reached menopause? Y / N At what age?

Do you have regular periods? Y / N




Substance Use


DRUG CATEGORY
(circle each substance used)

Age when

you first

used this:


How much & how often did you use this?

How many years did you use this?

When did

you last

use this?





Do you currently

use this?




ALCOHOL













Yes □ No □

CANNABIS:

Marijuana, hashish, hash oil















Yes □ No □

STIMULANTS:

Cocaine, crack















Yes □ No □

STIMULANTS:

Methamphetamine—speed, ice, crank















Yes □ No □

AMPHETAMINES/OTHER STIMULANTS:

Ritalin, Benzedrine, Dexedrine















Yes □ No □

BENZODIAZEPINES/TRANQUILIZERS:

Valium, Librium, Halcion, Xanax, Diazepam, “Roofies”















Yes □ No □

SEDATIVES/HYPNOTICS/BARBITURATES:

Amytal, Seconal, Dalmane, Quaalude, Phenobarbital















Yes □ No □

HEROIN













Yes □ No □

STREET OR ILLICIT METHADONE













Yes □ No □

OTHER OPIOIDS:

Tylenol #2 & #3, 282’S, 292’S, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid














Yes □ No □

HALLUCINOGENS:

LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide














Yes □ No □

INHALANTS:

Glue, gasoline, aerosols, paint thinner, poppers, rush, locker room















Yes □ No □

OTHER: specify)_________________________________________________________________________________________________________













Yes □ No □




Physician initials _______


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