New Patient Demographics and History

Demographics
Patient Name*

First NameLast Name
Patient’s sex*

MaleFemaleOther
Patient’s Date of Birth*

MonthDayYear
Date
Patient’s Social Security Number
Patient’s Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact number for patient*

Area CodePhone Number
Patient Work Number

Area CodePhone Number
Patient’s Email*
example@example.com
Employment Status of Patient

Full TimePart TimeNot WorkingDisabledRetiredStudentOther
Name of Employer
Marital Status of Patient

SingleMarriedDivorcedWidowedOther
Language(s) spoken by patient

EnglishSpanishOther
What category best describes your race (one or more may be marked)

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteI choose not to answerOther
Please specify your ethnicity

Hispanic or LatinoNot Hispanic or Latino
Nationality of Patient

U.S. citizenOther
Emergency Contact Information
Emergency Contact for patient*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How is the emergency contact related to patient?
Other Contact Name

First NameLast Name
Other Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Contact Phone Number

Area CodePhone Number
How is other contact related to the patient?
Pharmacy Information
What pharmacy do you use locally?*
Local Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Pharmacy Phone Number

Area CodePhone Number
What is your mail order pharmacy?
Primary Insurance Information
Insurance Company Name (primary)
Subscriber’s Insurance ID number
Group Number
Primary Insurance Effective Date

MonthDayYear
Date
Primary Insurance Subscriber’s Name
Primary Insurance Subscriber’s Date of Birth

MonthDayYear
Date
Primary Insurance Subscriber’s Sex

FemaleMale
Patient’s relationship to subscriber of Primary Insurance

SpouseChildOther
Secondary Insurance Information
Secondary Insurance Carrier
Secondary Insurance Subscriber ID number
Secondary Insurance Subscriber’s Name
Secondary Insurance Subscriber’s Date of Birth

MonthDayYear
Date
Secondary Insurance Subscriber’s Sex

FemaleMale
Patient’s relationship to subscriber of Secondary Insurance

SpouseChildOther
Any other information you feel we need to know?
Patient Medical History
Have you ever been treated any of the following medical conditions?

Acid Reflux (GERD)ArthritisAsthmaBleeding DisordersCancerChronic painCOPD/EmphysemaDementia or memory lossDiabetes mellitusHead trauma/loss of consciousnessHeart disease/heart attackHepatitis BHepatitis CHigh blood pressureHigh cholesterolHigh thyroid functionHIV diseaseIron deficiency/anemiaIrritable Bowel SyndromeKidney diseaseLow thyroid functionMigraines or chronic headachesParkinson's diseasePituitary tumorSeizures/epilepsySleep apneaStroke or TIA (min-stroke)Vitamin B12 deficiencyVitamin D deficiencyNoneOther
Please list any other medical conditions not listed above
Medication Allergies/Adverse Reactions
Surgical History
Current Medications
Primary Care Provider Name

First NameLast NameSuffix
Primary Care Provider Phone Number

Area CodePhone Number
Your other healthcare providers
Psychiatric History
Previous mental health provider
Therapist/Counselor Name

First NameLast Name
Therapist/Counselor Phone Number

Area CodePhone Number
Psychiatric Hospitalizations/Rehab/IOP or PHP
Please list any information on past suicide attempts
Please list information on any history of self harm or mutilation
There is another form available to list past medication trials. If you have tried medications or non-medication interventions like ECT, TMS, etc, please complete that form.
Please provide any additional information you think your provider should know about your psychiatric history. Thank you.
Family History
Parents' History
Siblings' History
Children's History
Other relatives with relevant psychiatric history
Patient Developmental History
Please list any complications with your pregnancy/birth/delivery
Please list any developmental delays and treatments for them that you underwent as a child (OT, PT, speech therapy, etc)
Please list any learning issues and treatments received as a child (include speech therapy, OT, IEP/540, etc)
Did you have any issues making friends or connecting to people when you were young?
Personal History
Where were you born and raised?
With whom did you grow up

Both parentsMotherFatherOther relativeAdoptedOther
Highest level of eduation

Non-HS graduateGEDHigh School2 year degree4 year degreeGraduate degreePost graduateVocational training
Marital Status

Single, never marriedDivorced and singleDivorced and remarriedWidowed and singleWidowed and remarriedSeparatedPartneredMarriedOther
Partner's name
Years together
With whom do you live?
Employment

Full TimePart timeStay at homeRetiredUnemployed/not workingFurloughedShort term disabilityLong term disabilityStudentSelf employedOther
Occupation
Employer
What branch(es)?

Air ForceArmyCoast GuardMarinesNational GuardNavyOther
How long did you serve?
Legal History

NoneArrestDUIJail/Prison timeCurrently on probationOther
Please list hobbies and interests/community organizations that you enjoy.
Regular Exercise

NoneCardioWeight trainingOther
Pets at home
Have you ever been the victim of violence?

EmotionalDomestic violencePhysicalSexualWitnessed abuse/violenceNoneOther
Substance Use History
How many servings of caffeine do you consume in an average day?

Recreational Drug use

	Past Use	Current Use	Rehab
Cannabis/THC
Cocaine/crack
Meth
Stimulants
Ketamine
MDMA (Ecstasy)
Psilocybin (shrooms)
LSD
Huffing
Pain pills/Heroin

Alcohol Use
Alcohol Quantity
Have you ever experienced any of the following due to alcohol use?

BlackoutsWithdrawal seizureOther severe withdrawal symptoms (high BP, high HR, agitation, confusion)Delirium tremendous (DTs)-requires hospitalizationMild withdrawal symptoms (nausea, shakes, sweating)Memory lossNeeding an “eye opener”-drinking upon wakeningCraving alcohol when not drinking
Have you required the following treatment due to alcohol use?

Medical hospitalization for detoxNon-ICU Detoxification>90 day residential treatment30-60 day residential treatmentLong term sober livingIntensive outpatient rehab programAlcoholic Anonymous or other recovery program
Any other information regarding substance use that you feel your provider needs to know?
Is there anything else you feel your provider needs to know? Any specific issues you hope to address at your first appointment?
Should be Empty:

Demographics

Emergency Contact Information

Pharmacy Information

Primary Insurance Information

Secondary Insurance Information

Patient Medical History

Psychiatric History

Family History

Patient Developmental History

Personal History

Substance Use History