New Patient Clinical Questionnaire
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Medication History
Helpful
Not Helpful
Currently Taking?
Adverse Reaction?
Comments
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine (Luvox)
Citalopram (Celexa)
Escitalopram (Lexapro)
Desipramine (Norpramin)
Imipramine (Tofranil)
Doxepin (Sinequan)
Clomipramine (Anafranil)
Nortriptyline (Pamelor)
Bupropion (Wellbutrin)
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)
Vortioxetine (Trintellix)
Vilazodone (Viibryd)
Paliperidone (Invega)
Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Loxapine (Loxitane)
Fluphenazine (Proloxin)
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quatran (Seroquel)
Risperidone (Risperdal)
Cariprazine (Vraylar)
Brexpiprazole (Rexulti)
Aripiprazole (Abilify)
Alprazolam (Xanax)
Diazepam (Valium)
Buspirone (BuSpar)
Lorazepam (Ativan)
Clonazepam (Klonopin)
Hydroxyzine (Vistaril, Atarax)
Buprenorphine (Suboxone)
Varenicline (Chantix)
Methadone (Dolophine)
Carbamazepine (Tegretol)
Oxcarbazepine (Trileptal)
Valproate (Depakene)
Lamotrigine (Lamictal)
Gabapentin (Neurontin)
Topiramate (Topamax)
Olanzapine (Zyprexa)
Lithium (Eskalith)
Methylphenidate (Ritalin, Concerta)
Amphetamine (Adderall)
Lisdexamfetamine dimesylate (Vyvanse)
Medical and Psychiatric History
This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every questions to the best of your ability.
Are you in good physical health?
Yes
No
Has there been any change in your general physical health in the last year?
Yes
No
Have you ever had any serious illness or operation?
Yes
No
If you had a serious illness or operation, please elaborate
Are you currently under the care of a physician for any physical condition?
Yes
No
Please list your current medications
Name of Medication
Strength of Medication
Date Began
Reason for Taking
1
2
3
4
5
6
7
8
9
10
Please list any non-prescription drugs, including natural remedies and vitamins you are currently taking:
Name of Medication
Strength of Medication
Date Began
Reason for Taking
1
2
3
4
5
6
7
8
9
10
If you have any adverse reactions or allergies to medications please list below:
Name of Medication
Reaction
1
2
3
4
5
Have you ever been hospitalized?
Yes
No
If so, please list and explain your hospitalizations:
Reason for Hospitalization
Date of Hospitalization
Location
Treatment Received
1
2
3
4
5
6
7
8
9
10
Please select all of the following that apply to you:
Cancer
Rheumatic Fever
Lupus or Autoimmune Disease
Arthritis or Rheumatism
Chronic Pain or Complex Regional Pain
Disc Disease
Stomach Ulcer
Gastroesophageal Reflux
Irritable Bowel Syndrome
Colitis
Liver Disease
Hepatitis or Jaundice
Cardiovascular Disease or Heart Failure
Heart Attack or Myocardial Infarction
High Blood Pressure
Coronary Artery Disease/Arteriosclerosis
Diabetes/High Blood Sugar
Under Active Thyroid
Overactive Thyroid
Anemia
Blood Clotting Problems
Tuberculosis
Asthma
Hay Fever or Seasonal Allergies
Hives or Skin Rashes
STD/ Venereal Disease
Sexual or Erectile Disfunction
Bladder Problems
Kidney Disease/Kidney Stones
Migraine/Tension Headaches
Fainting Spells
Seizures or Convulsions
Parkinson's Disease
Dementia or Alzheimer's Disease
Glaucoma
Fibromyalgia
Lyme Disease
Other
In chronological order, please list all psychiatrist or psychotherapists (psychologists, therapists, nurse practitioners, etc.)
Provider Name and Location
Dates/Duration of Seeing Provider
Treatment Received
1
2
3
4
5
During the last four (4) weeks, have you been bothered by any of the following?
Stomach Pain
Back Pain
Pain in your arms, legs, or joints
Menstrual cramps or problems with your period
Headaches
Chest Pains
Dizziness
Fainting spell
Feeling your heart pound or race
Shortness of breath
Constipation
Loose bowel or diarrhea
Nausea, gas, or indigestion
Over the last two (2) weeks, have you been bothered by any of the following?
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling asleep or staying asleep
Sleeping too much
Feeling tired or low energy
Poor appetite or over-eating
Feeling bad about yourself
Feeling that you are a failure or have let others down
Trouble concentrating (watching TV, reading, etc.)
Moving or speaking slowly that other people have noticied
Being so fidgety or restless that other people have noticed
Thoughts you would be better off dead or hurting yourself
Persistently elevated, expansive mood (manic)
Inflated self-esteem
Pressured to keep talking
Racing thoughts
Distractibility (including being diagnosed with ADD or ADHD)
Impulsiveness (buying sprees, sexual indiscretions, foolish investments)
Hallucinations (auditory, visual symptoms)
Paranoia (believing others are out to harm or hurt you)
In the last four (4) weeks have you had an anxiety attack?
Yes
No
Related to your anxiety attack, has this happened before?
Yes
No
Related to your anxiety attack, do some of these attack come suddenly out of the blue or in situations where you don't expect to be nervous or uncomfortable?
Yes
No
Related to your anxiety attack, do these attacks bother you a lot or are you worried about having another?
Yes
No
Think about your last bad anxiety attack, did you experience any of the following?
Shortness of beath
Heart race
Chest Pain or Pressure
Feeling as if you were choking
Hot Flashes or Chills
Nausea or upset stomach
Dizzy, unsteady or faint
Tremble or shake
Afraid of dying
None of the above
Over the last four (4) weeks, which of the following problems have you experienced:
Feeling nervous, on edge, or worried about different things
Feeling restless so that it's hard to sit still
Getting tired very easily
Muscle tension, aches, or soreness
Trouble falling asleep or staying asleep
Trouble concentrating on things such as reading and watching TV
Obsessions (fear of contaminations, need for order or symmetry)
Becoming easily annoyed or irritated
Compulsions (checking doors, oven, washing hands)
Social Anxiety (center of attention, avoiding social situations)
None of the above
Select any of the following you experience while eating
Feel you can't control what or how much you eat
Often eat within 2 hour period what most people would regard as an unusually large amount of food
Fear of gaining weight or feeling fat
Frequently diet or restrict your caloric intake
None of the above
In the last three (3) months, have you often done any of the following to avoid gaining weight?
Made yourself vomit
Taken more than twice the recommended dose of laxatives
Fasted (not eaten anything at all for the last 24 hours)
Exercised for more than an hour, specifically to avoid gaining weight after binge eating
None of the above
If you marked any of the ways of avoiding gaining weight, were any as often or average of twice a week?
Yes
No
Do you ever drink alcohol, including beer and wine?
Yes
No
Select the following that have happened to you more than once in the last six (6) months
Drank alcohol even though a doctor suggested you stop drinking because of a problem with your health
You drank alcohol, were intoxicated, or were hungover going to school, work, or taking care of someone else's children or other responsibilities
You missed or were late to work, school, or other activities because you were drinking or hungover
You have problems getting along with others while drinking
You drove a car after having several drinks or drinking too much alcohol
Do you presently use recreational drugs (If yes, please explain)?
Have you ever used alcohol or drugs more than you do now (if yes, please explain)?
Please select the following that apply to you
Vaped (e-cigarette) in your lifetime
Currently a smoker of cigarettes
Used to smoke cigarettes
Drink more than 6 cups of coffee a day
Drink more than 2+ caffeinated beverages per day
In the last four (4) weeks, select the following that you have been bothered by:
Worrying about your health
Your weight or how you look
Little or no sexual desire or pleasure during sex
Difficulties with your significant other
Stress related to taking care of family
Stress at work, school, or outside of the home
Financial problems or worries
Having no one to turn to when you have a problem
Something bad that happened recently
Thinking or dreaming about something terrible that happened to you in the past
Learning disability (Dyslexia, ADHD)
Unusually sensitivity to common noises such as someone eating, computer typing, pen clicking, etc.
In the last year have you been hit, slapped, kicked, or otherwise physically hurt by someone, or has anyone forced you to have unwanted sexual acts?
Yes
No
What is the most stressful thing in your life right now?
Has anyone in your family suffered from any psychiatric disorder (Bipolar, manic depression, anxiety disorder, ADHD, substance abuse, schizophrenia)? If so, please explain
What is your sex?
Male
Female
Other
Wish not to answer
Which of the following describes your menstrual period?
Periods are unchanged?
No period because of pregnancy of recent birth
Periods have become irregular or changed in frequency, duration, amount
No periods for at least one (1) year - Menopause
Having no periods because taking hormone replacement or contraceptive
During the week before your period starts, you experience problems with mood swings, depression, anxiety, irritability and anger.
None of the Above
Which of the following describes you?
Have given birth within the last six (6) months
Had a miscarriage within the last six (6) months
Having difficulty getting pregnant
None of the above
Please select which perimenopausal symptoms you experience
Hot flashes
Vaginal dryness
Irregular periods, mood instability, anxiety, depression
Have been prescribed hormone therapy
Have a change in libido or sexual interest
None of the above
Please select the following that apply to you
Difficulty maintaining an erection
Change in libido or sexual interest
Treated for Erectile Dysfunction
Prescribed Viagra, Cialis, or Levitra
Treated for low testosterone
Treated for Peyronie's disease
None of the Above
Have you ever Hit your Head or been Hit on the Head? (think about incidents that have occurred at any age)
Yes
No
Were you ever seen in the Emergency room, hospital, or by a doctor because of an injury to your head?
Yes
No
Did you ever Lose consciousness or experience a period of being dazed and confused because of an injury to your head?
Yes
No
Do you experience any of the following problems in your daily life since you hit your head?
Headaches
Dizziness
Anxiety
Depression
Difficulty Concentrating
Difficulty Remembering
Difficulty Reading, Writing, or Calculating
Poor Problem Solving
Difficulty Performing Job/School Work
Change in Relationships with Others
Poor Judgement (Being Fired from Job, Arrests, Fights)
None of the Above
Any significant sicknesses due to a blow to the head?
Yes
No
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