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NEW PATIENT BACKGROUND QUESTIONNAIRE
Patient Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Gender
Marital Status (Choose one)
Single
Married
Divorced
Separated
Widowed
Number of Children
Pharmacy Name
Pharmacy Address
Pharmacy phone number
Please enter a valid phone number.
If patient is a minor, who has legal guardianship? (check one)
Both biological parents living in the home with the child
Both biological parents have joint custody, but parents are divorced or separated
Other custodial arrangement, please describe in the box after this section
Only one parent has custody, name of custodial parent
Only fill out if you responded as 'Other custodial arrangements' in the section above
Referral Source
Reason for seeking treatment
Prior inpatient mental health treatment
(include hospital admissions and partial hospitalization program)
Start Date
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Month
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Day
Year
Date
End Date
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Month
-
Day
Year
Date
Name of Facility
Start Date
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Month
-
Day
Year
Date
End Date
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Month
-
Day
Year
Date
Name of Facility
Start Date
-
Month
-
Day
Year
Date
End Date
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Month
-
Day
Year
Date
Name of Facility
Prior outpatient mental health treatment history
(include any treatment from psychiatrist, psychiatric nurses, therapists, etc.)
Start Date
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Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Name of Provider
Start Date
-
Month
-
Day
Year
Date
End Date
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Month
-
Day
Year
Date
Name of Provider
Start Date
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Month
-
Day
Year
Date
End Date
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Month
-
Day
Year
Date
Name of Provider
Please describe any history of substance abuse problems and/or treatment
Please list all medication currently prescribed for the patient
(include both psychiatric and non psychiatric medications)
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Name
Dose / Instructions
Prescriber
Please list all psychiatric medications taken in the past that have been discontinued
Please list any medication allergies
Please list history of medical problems and surgical procedures
Use the following scale to describe how often the following statements apply to the patient
0=Never 1=Rarely 2=Occasionally 3=Frequently 4=Almost Always
Feeling sad
Appetite change
Decreased level of energy
Thoughts about self-injury
Racing or hard to track thought pattern
Being easily distracted
Impulsive behaviors
Obsessive thought
Recall of past traumatic events
Eating too much or too little
Fears that people will or may want to harm you
Decreased interest or pleasure in usual activities
Sleep problems or changes
Thoughts of death or suicide
Increased energy level
Decreased amount of sleep without feeling tired
Increased level of activities
Feeling anxious or nervous
Repetitive or compulsive behaviors
Hearing voices or seeing things others can't
Being easily startled
Submit
Should be Empty: