ID Information for Intake Form

Please fill this form out, submit it, and then proceed to fill out and submit the "Initial Intake Form" below it.


If none, write "N/A"
This is so I can match it with the Initial Intake Form, which does not have an ID attached to it (that you will fill out next, below.)
Date of Birth *
Date of Birth
Home Address *
Home Address
Home Phone *
Home Phone
Cell Phone *
Cell Phone
(If currently dependent on parents or younger than 18)
 

Initial Intake Form

Do not fill out this form until you have completed and submitted the "ID Information for Intake Form" above. Once this is complete, please fill out and submit the form below.


This is for me to match with your "ID Information for Intake Form" above, which you should have filled out and submitted, prior to starting this form.
Date *
Date
(Please include the date you started taking them, the dosage, and the side effects)
(Please include the date you started taking them, the dosage, and the side effects.)
(Please include the date you started taking them, duration of use, the dosage, and the side effects.)
This includes your condition over the past month: What does it feel like to be in your shoes (i.e. what are your symptoms)? How are you feeling (mood and stress level)? How is your cognitive state of health (i.e. attention, focus, memory). Describe your sleeping pattern. Do you have difficulty falling asleep, staying asleep, or waking up early? Describe your appetite and eating patterns. Any history of an eating disorder, either anorexia or bulimia? Have you been compliant with treatment? Are you suicidal or homicidal?
When did you start to experience difficulties with your mental health, e.g. at what age did it all begin? Was it a gradual onset or did it occur due to a specific trauma or event? What have you tried in the past for treatment for your mental health condition. How did your treatments work out for you? Have you been hospitalized before for these problems?
What types of medical problems have you had in the past? What treatment has been tried? Past hospitalizations? Surgeries? Infections? What did or did not work for you?
Describe your family now and when you were a child. What is going on in your life socially? What types of stressors are currently a part of your life? What is your occupation? Have you ever been traumatized through abuse or neglect?
Describe your type and level of activity and exercise. What is your current height and weight? Did you ever struggle with your weight? Do you like to exercise?
Describe your spiritual and religious background and beliefs. How would you describe your attitude and relationship with God? Have you had any spiritually transformative experiences? Have you ever had an out of body experience, or near death experience? How does your health condition affect your spiritual life and attitude towards God? If you do not believe in a spiritual life or God, what is your highest value in life that gives your life purpose and direction?
Was your gestation healthy? Were you born premature? Did you have difficulties mentally or physically when you were young? Did you ever get in an accident that broke a bone or hurt your head? Did you experience mental, emotional, or physical traumas growing up? Have you ever had jaundice, Mono, hepatitis, or H. Pylori? Did you have frequent strep or ear infections? Were you breast fed or bottle fed as an infant?
What do you like to eat? What would be a typical day for you with respect to the foods that you eat for breakfast, lunch, dinner, and snacks? What types of foods and in what quantities do you eat in the category of junk food, snacks, diet sodas, gum, candies, desserts, and processed foods? Do some foods make you feel tired or wiped out? Did you ever have a dairy or wheat allergy?
What kind of diseases, both physical and emotional tends to run in your family? What kinds of diseases ended the lives of your relatives? Does substance abuse run in the family?
Have you had a problem with a sensitive stomach, gastric reflux, diarrhea, constipation, or bloating? Have you ever had ulcers or surgery of the G.I. system? e.g. gall bladder removal. Do you have diabetes? Problems with low blood sugars?
Do you get sick and catch a cold or flu regularly? Have you taken a great deal of antibiotics in your lifetime? Do you have seasonal or food allergies?
Did you develop smoothly and normally as you transitioned into adolescence? Do you ever wonder if you have a thyroid problem because of problems with weight gain, dry skin, or overall sluggishness? For women: do you have normal cycles?
How are your bones and muscles? Do you ache all over and have problems with weak bones? How are your joints?
How are your bladder, kidneys, and sexual organs functioning? Do you experience problems with urination, libido, or water balance? Have you had a history of bladder or kidney infections?
If not applicable - please write "N/A"
If not applicable - please write "N/A"
If not applicable - please write "N/A"
If not applicable - please write "N/A"
What are you like when you are “well.” What is it that we are aiming for as a target state of mind? How long ago has it been that you have felt “normal and happy?”

 

Thank you for taking the time to provide your medical history and for your interest in my holistic psychiatry practice.