NEW PATIENT PAPERWORK PART II

JOHN W GRACE, M.D. INTAKE FORM

IF A REQUIRED CATEGORY DOES NOT APPLY TO YOU TYPE: "N/A"
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
(CHIEF COMPLAINT) WHY ARE YOU SEEKING TREATMENT AT THIS TIME? *
WHO REFERRED OR SUGGESTED YOU COME AND WHY? *
WHO ARE YOUR CURRENT HEALTH CARE PROVIDERS? *
WHICH OF THE FOLLOWING MEDICAL CONDITIONS HAVE YOU HAD *

NONE OF BELOW APPLY TO ME Chronic pain (Describe source below) Head injury with loss of consciousness. Stroke Diabetes Thyroid Problems COPD (emphysema) Multiple sclerosis. Parkinson’s Disease High Blood Pressure High Cholesterol Chronic Kidney Failure Heart Disease Glaucoma Restless Legs Fibromyalgia Rheumatoid Arthritis Neuropathy Lyme Disease Lupus
ADDITIONAL MEDICAL CONDITION OR ELABORATION. PLEASE DESCRIBE SOURCES OF CHRONIC PAIN. *
SURGICAL HISTORY (WHAT AND WHEN) *
CURRENT MEDICATIONS AND SUPPLEMENTS (DOSE AND HOW TAKEN) *
ALLERGIES (MEDICATIONS, FOOD, ENVIRONMENTAL) WHAT HAPPENS? *
REVIEW OF SYMPTOMS WHICH OF THE FOLLOWING SYMPTOMS CURRENTLY APPLY? (EXPLAIN IN NEXT BOX) *

NONE OF BELOW APPLY Weight loss Weight gain. Fever Fatigue Changes in your skin Changes in nails Open sores or rashes Itching Lumps or moles that are new or changed? Headaches Head Trauma Seizures Glaucoma Vision problems Hearing problems Ringing in ears Room spinning Ear Pain Nose bleed Runny nose Bleeding or soreness in your mouth or tongue Sore throat Hoarseness Swollen glands Lumps or nodules in breasts Discharge from the breasts Chest pains Heart beating too fast Shortness of breath Any wheezing Swelling in the feet Coughs Problem swallowing Indigestion or heartburn Nausea and vomiting Diarrhea Constipation Increase or decreased appetite Changes in your stool Increased or Decreased Urination Problems urinating Change in color or smell or urine Change in frequency of urine Urinating at night Drinking a lot Incontinence Changes in periods Vaginal discharge There is a history of pregnancy There is a chance I'm currently pregnant Sexual Difficulties Impotence Erection Problems Discharge from penis Pain in Joints Swelling of feet or legs My fingers change color in cold Seizures Tremors Weakness or unusual sensations Tremors Easy bruising or bleeding Intolerance of heat or cold Blanking out, where you didn't remember where you were or how you gotthere Traveled out of the country
PLEASE ELABORATE ON ANY ABOVE CHECKED BOXES *
WHICH DESCRIBE YOUR MENTAL HEALTH SYMPTOMS? *

GENERAL TRAITS: I am easily overwhelmed. GENERAL TRAITS: I can manage a lot of things but have a history of overextending myself. GENERAL TRAITS: I tend to take care of others and neglect myself. MEMORY: I have had some significant memory issues TICS: Even though they are embarrassing and I can suppress them, I have tics. A tic is a sudden, repetitive, nonrhythmic motor movement or vocalization. Examples include abdominal tensing, toe crunching, eye blinking, and throat clearing. HOARDING :I have a real problem holding onto things excessively, to the point that it affects my space or lifestyle. OBSESSIONS: I have really clear and specific obsessions (with germs, numbers, rituals, etc) that take up at least thirty minutes of my day and sometimes many more. OBSESSIONS: I tend to think in circles when nervous. ANXIETY: I tend to worry about everything. ANXIETY: I have had panic attacks. SOMATIZATION: I have had a lot of physical complaints that seem related to emotional state. MANIA: I have a family hx. of bipolar disorder. MANIA: I have had really clear mania in past. Periods where sleep was not required without any feelings of tired. This was not related to either taking or withdrawing from any substances or medication. MANIA: I have a history of clear seasonality to mood. MANIA: I have had possible mania or cyclic irritability. MANIA: I am a night owl. DEPRESSION: I have had multiple episodes of severe depression DEPRESSION: I have never been a happy person. DEPRESSION: I use to be a fairly happy person but it has been some time since they enjoyed anything. DEPRESSION: I lack energy. DEPRESSION: I lack focus. DEPRESSION: I lack get up and go. ATTENTION DEFICIT DISORDER: I have trouble focusing throughout life including paying attention throughout childhood in school. decompensation. PSYCHOSIS: I nearly always have some level of reality disturbance in the form of paranoia or hallucinations. PSYCHOSIS: I occasionally have disturbance in reality. PSYCHOSIS: My mind sometimes plays tricks. PSYCHOSIS: I have hallucinations. ANGER PROBLEMS: I have a problem with temper. ANGER PROBLEMS: I overreact to stress.r during ANGER PROBLEMS: I overreact to small insults. ANGER PROBLEMS: I am triggered by disrespect. ANGER PROBLEMS: I am triggered by authority figures. ANGER PROBLEMS: I can have severe anger during decompensation. PTSD: Some of the traumatic events I've lived through still haunt me in dreams, flashbacks, or being triggered by them.
ELABORATE OR CLARIFY ANY OF THE ABOVE SYMPTOMS. *
PSYCHIATRIC HOSPITALIZATIONS (WHEN AND FOR WHAT?) *
PREVIOUS PSYCHOTHERAPY (WHEN, HOW LONG, AND TYPE OR FOCUS) *
TRAUMATIC EVENTS *

I am a survivor of horrible childhood abuse. I have experienced severe bullying in childhood. I was sexually assaulted as an adult. I have dealt with physically abusive relationships. I was verbally abused in past relationships. I have had a lot of trauma from medical procedures. I have survived severe motor vehicle accidents. I served in the military and experienced life threatening combat. I have lost a young child.
WHICH OF THE ABOVE EVENTS MOST CHANGED YOU? IN WHAT WAYS? *
FAMILY MEDICAL CONDITIONS (WHO AND WHAT) *
FAMILY PSYCHIATRIC CONDITIONS (WHO AND WHAT) (SUBSTANCE USE, DEPRESSION, ANXIETY, BIPOLAR) *
(UPBRINGING) WHERE WERE YOU BORN? HOW MANY SIBLINGS DID YOU HAVE? WHAT KIND OF WORK DID YOUR PARENTS DO? WHAT WERE YOU LIKE AS A CHILD (OUTGOING, SHY, ATHLETIC)? WERE THERE ANY PROBLEMS AT HOME OR SCHOOL? (BULLYING, POOR ACADEMICS, PHYSICAL, MENTAL, SEXUAL ABUSE) *
(VOCATIONAL HISTORY)WHAT KIND OF WORK HAVE YOU DONE THROUGH LIFE AND ARE CURRENTLY DOING? IF YOU ARE DISABLED FROM WORK, HOW LONG AND FROM WHAT CONDITIONS? *
EDUCATION HISTORY: DESCRIBE HOW FAR YOU WENT IN SCHOOL, AREAS OF STUDY, STRENGTHS AND STRUGGLES: *
MILITARY HISTORY: BRANCH OF THE SERVCE DATES OF SERVICE RANK AT DISCHARGE TRAUMATIC EVENTS DURING SERVICE DISCIPLINARY ACTIONS DURING SERVICE *
RELATIONSHIP HISTORY: DESCRIBE SIGNIFICANT PAST RELATIONSHIPS INCLUDING MARRIAGES, CHILDREN AND FRIENDSHIPS *
LEGAL HISTORY (ARRESTS, CHARGES, WHEN OCCURRED): *
WHAT IS YOUR CURRENT LIVING SITUATION? HOW DO YOU SUPPORT YOURSELF? WHO IS YOUR SUPPORT SYSTEM? WHAT IS THE STRENGTHS AND WEAKNESSES OF YOUR SUPPORT SYSTEM? *
ALTERNATIVE REMEDIES TRIED IN PAST *

Vitamin B12 Vitamin D Deplin Sam-E, 5-HTTP, CoQ10, Fish Oil, Flaxseed Oil, Melatnonin, St. John’s Wort
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
COGNITIVE ENHANCERS TRIED IN THE PAST *

Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne) Dextromethorphan / Quinidine (Neudexta)
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
ATTENTION DEFICIT MEDICATIONS TRIED IN THE PAST *

Methylphenidate (Ritalin, Concerta) Amphetamine and dextroamphetamine (Adderall) Dextroamphetamine (Dexadrine) Phentermine (Adipex-P, Lomaira) Lisdexamfetamine (Vyvanse) Modafinil (Provigil) Armodafinil (Nuvigil) Atomoxetine (Strattera) Clonidine Guanfacine (Tenex)
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
SLEEP AGENTS TRIED IN PAST *

Trazadone (Desryl), Melatonin Zolpidem (Ambien) Zaleplon (Sonata) Eszopiclone (Lunesta)l Temazepam (Restoril) Benadry Suvorexant (Belsomra) Doxepin (Sinequan)
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
MOOD STABILIZERS TRIED IN THE PAST *

Lithium Valproic Acid (Depakote) Lamotrigine (Lamictal) Carbemazipine (Tegretol), Haloperidol (Haldol) Ziprasidone (Geodon) Olanzipine (Zyprexa) Quetiapine (Seroquel) Aripiprazole (Abilify)). Oxcarbazepine (Trileptal) Levetiracetam (Keppra) Topiramate (Topamax) Gabapentin (Neurontin) Pregabalin Lyrica Brexpiprazole (Rexulti) Lurasidone(Latuda) Pimavanserin (Nuplazid) Cariprazine (Vraylar)
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
ANXIETY TREATMENTS TRIED IN THE PAST *

(Lorazepam (Ativan) Alprazolam (Xanax) Diazepam (Valium) Buspirone (Buspar) Triazolam (Halcyon) Clonidine (Catapras) Prazosin (Minipres) Baclofen Tizanidine (Zanaflex) Hydroxizine (Vistaril)
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
DEPRESSION TREATMENTS TRIED IN THE PAST *

Ketamine derivatives Electroconvulsive Therapy Transcranial Magnetic Therapy Vagus Nerve Stimulation Deep Brain Stimulation Botox Injections Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Venlafaxine (Effexor) Mirtazapine (Remeron) Buproprion (Wellbutrin, Zyban) Citalopram (Celexa) E-Citalopram (Lexapro) Amitryptiline (Elavil) Nortriptiline (Pamelor) Clomipramine (Anafranil) Doxepin (Sinequan) Vilazadone (Viibryd) Vortioxetine (Trintellix) Phenylzine (Nardil)
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE *
CURRENTLY USING *

NONE OF BELOW APPLY IN THIS CATEGORY Alcohol Caffeine Marijuana Sedatives (valium, xanax, etc) Painkillers (oxycontin, heroin, kratom) Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)
DESCRIBE FREQUENCY AND AMOUNT OF USE *
MISUSED BRIEFLY IN THE PAST *

NONE OF BELOW APPLY IN THIS CATEGORY Alcohol Caffeine Marijuana Sedatives (valium, xanax, etc) Painkillers (oxycontin, heroin, kratom) Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)
HAD SIGNIFICANT PROBLEMS FROM IN PAST *

NONE OF BELOW APPLY IN THIS CATEGORY Alcohol Caffeine Marijuana Sedatives (valium, xanax, etc) Painkillers (oxycontin, heroin, kratom) Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)
DESCRIBE PATTERN AND PROBLES *
PROLONGED TREATMENT FOR IN PAST *

NONE OF BELOW APPLY IN THIS CATEGORY Alcohol Caffeine Marijuana Sedatives (valium, xanax, etc) Painkillers (oxycontin, heroin, kratom) Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)
DESCRIBE TREATMENTS *
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JOHN W GRACE, M.D. INTAKE FORM