Psychiatry Forms Psychiatry Packet Psychiatry Packet Name * Name First First Last Last Birthday * Phone * Date: * MRN#: What brings you in? * What are your goals with Dr. Gerber? * Current Symptoms Checklist: * Depressed Mood Crying Spells Anxiety Attacks Unable To Enjoy Activities Racing Thoughts Avoidance Sleep Pattern Disturbance Impulsivity Hallucinations Loss Of Interest Increase Risky Behavior Suspiciousness Concentration/Forgetfulness Increased Libido Excessive Worry Change In Appetite Excessive Energy Decreased Libido Excessive Guilt Increased Irritability Fatigue Excessive Worry General Stress Level: * Low Moderate High Is the method you would use readily available? Suicide Assessment: Do you have access to guns? * Yes No If yes, please explain: Have you ever had feelings or thoughts that you didn’t want to live? Yes No If you answered no, skip to “Past Psychiatric History” section. If yes, continue. Do you currently feel that you don’t want to live? Yes No How often do you have these thoughts? When was the last time you had thoughts of dying? Has anything happened recently to make you feel this way? On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently? Would anything make it better? Have you planned a time for this? Is there anything that would stop you from killing yourself? Do you feel hopeless and/or worthless? Have you ever tried to kill or harm yourself before? Past Psychiatric History: Outpatient treatment? * Yes No If yes, please describe when: Date: By whom: Nature of treatment: Psychiatric Hospitalization? * Yes No If yes, describe for what reason: Date Hospitalized: Where: Past Psychiatric Medications If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can’t remember all the details, just write in what you do remember) Antidepressants: Prozac (fluoxetine) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Wellbrutrin (bupropion) Remeron (mirtazapine) Serzone (nefazodone) Anafranil (clomipramine) Pamelor (nortrptyline) Tofranil (imipramine) Elavil (amitriptyline) Other: Mood Stabilizers: Tegretol (carbamazepine) Lithium Depakote (valproate) Lamictal (lamotrigine) Topamax (topiramate) Other: Antipsychotics/Mood Stabilizers: Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Abilify (aripiprazole) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Risperdal (risperidone) Other: Sedative/Hypnotics: Ambien (zolpidem) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) Other: ADHD Medications: Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Other: Antianxiety Medications: Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) Other: Has any family members been treated with a psychiatric medication? * Yes No If yes, who was treated, what medications did they take, and how effective was the treatment? (If known): Personal and Family Medical History: *Please indicate if it was YOU, or Family Member(s), as well as the Doctor/Facility that did the diagnosis)* **Please limit this to the first degree relatives.** ADD/ADHD Anxiety Disorder Abuse/Domestic Violence Anemia Asthma TexBipolar Disorder COPD Cancer Congestive Heart Failure Constipation Coronary Artery Disease Depression Diabetes Eating Disorder Fibromyalgia GI Problems Headaches Heart Disease Hepatitis High Cholesterol Hypertension Hyperthyroidism Hypothyroidism Educational History: Highest grade completed? * Did you attend college? * Yes No Major? What is your highest educational level or degree attained? * Section Trauma History: Do you have a history of being abused emotionally, sexually, physically, or by neglect? * Yes No Please describe when, where, and by whom? Substance Abuse: Have you ever been treated for alcohol or drug use or abuse? * Yes No If yes, for which substance? If yes, where were you treated and when? Check if you have ever tried the following: Have you ever tried Methamphetamine? * Yes No If yes, how long and when did you last use? Have you ever tried Cocaine? * Yes No If yes, how long and when did you last use? Have you ever tried Stimulants (pills)? * Yes No If yes, how long and when did you last use? Have you ever tried Heroin? * Yes No If yes, how long and when did you last use? Have you ever tried LSD or Hallucinogens? * Yes No If yes, how long and when did you last use? Have you ever tried Marijuana? * Yes No If yes, how long and when did you last use? Have you ever tried Pain Killers (not prescribed)? * Yes No If yes, how long and when did you last use? Have you ever tried Methadone? * Yes No If yes, how long and when did you last use? Have you ever tried Alcohol? * Yes No If yes, how long and when did you last use? Have you ever tried Ecstasy? * Yes No If yes, how long and when did you last use? Have you ever tried Steroids? * Yes No If yes, how long and when did you last use? Have you ever tried Tranquilizer/sleeping pills? * Yes No If yes, how long and when did you last use? Have you ever tried Other? * Yes No If yes, what, and for how long and when did you last use? Occupational History: Are you currently: * Working Student Unemployed Disabled Retired What is/was your occupation? * Where do you work? How long in present position? Have you ever served in the military? * Yes No If yes, what branch and when? Honorable discharge? * Yes No Family Background and Childhood History? Were you adopted? * Yes No Where did you grow up? * List your siblings and their ages: What was your father’s occupation? What was your mother’s occupation? Did your parents divorce? Yes No If so, how old were you when they divorced? If your parents divorced,, who did you live with? Describe your father and your relationship with him: Describe your mother and your relationship with her: How old were you when you left home? Has anyone in your immediate family died? Who and when? Relationship History and Current Family: Are you currently: * Married Partnered Divorced Single Widowed If not married, are you currently in a relationship? Yes No If yes, how long? Are you sexually active? Yes No How would you identify your sexual orientation? Straight/Heterosexual Lesbian/Gay/Homosexual Bisexual Transsexual Unsure/Questioning Asexual Other Prefer not to answer What is your spouse or significant other’s occupation? Describe your relationship with your spouse or significant other: Have you had any other prior marriages? Yes No If so, how many? How long? Do you have children? Yes No If yes, list ages and gender: Describe your relationship with your children List everyone who currently lives with you: Legal History: Have you ever been arrested? Yes No Do you have any pending legal problems? Yes No Spiritual Life: Do you belong to a religion or spiritual group? * Yes No If yes, what is the live of your involvement? Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you? More Helpful More Stressful Miscellaneous Medical Information: Are you legally blind? Yes No Left eye only Right eye only Both eyes Are you deaf? Yes No Left ear only Right ear only Both ears Is there anything else that you would like us to know? Mood Disorder Questionnaire: Has there ever been a period of time when you were not your usual self and … … you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? Yes No … you were so irritable that you shouted at people or started fights or arguments? Yes No … you felt much more self-confident than usual? Yes No … you got much less sleep than usual and found you didn’t really miss it? Yes No … you were much more talkative or spoke faster than usual? Yes No … thoughts raced through your head or you couldn’t slow your mind down? Yes No … you were so easily distracted by things around you that you had trouble concentrating or staying on track? Yes No … you had much more energy than usual? Yes No … you were much more active or did many more things than usual? Yes No … you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? Yes No … you were much more interested in sex than usual? Yes No … you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? Yes No … spending money got you or your family in trouble? Yes No If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Yes No How much of a problem did any of these cause you – like being able to work; having family, money, or legal troubles; getting into arguments or fights? Please check 1 response only: No problem Minor problem Moderate problem Serious problem Have any of your blood relatives [ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? Yes No Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? Yes No If you are human, leave this field blank. Submit Start Over
