New Patient Clinical Questionnaire

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)

Paroextine (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)

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

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

If you have any adverse reactions or allergies to medications please list below:

Name of Medication

Reaction

Have you ever been hospitalized?

Yes No

If so, please list and explain your hospitalizations:

Reason for Hospitalization

Date of Hospitalization

Location

Treatment Received

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

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
Should be Empty:

New Patient Clinical Questionnaire

Medical and Psychiatric History