New Patient Enrollment Form Bloom
Full Name
First Name
Last Name
Which Location are you seeking treatment at?
Murrysville
Greentree
What type of treatment are you seeking?
Psychiatric Med Management
Therapy
Date of birth:
-
Month
-
Day
Year
Date
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance:
Member ID:
Please Select Current Symptoms
Depressed mood
Low energy
Increased appetite
Restlessness
Drug use
Anorexia
Confusion
Suicidal thoughts
Self-injurious behavior (e.g., cutting, picking)
Muscle tension
Social anxiety
Ritualistic thoughts and/or behaviors
Isolation
Decreased hygiene
Sleep Disturbance
Impaired concentration
Decreased appetite
Fatigue
Elevated or euphoric mood
Bulimia
Hearing voices or noises others can't hear
Homicidal thoughts
Upset stomach / Nausea
Panic attacks
Talking or moving slowly
Nightmares
Decreased need for sleep
Inability to work
Low motivation
Memory deficits
Excessive worry
Excessive alcohol use
Excessive substance use
Binge eating
Seeing people or things that others can't see
Self-injurious thoughts
Physical pain
Difficult relaxing
Intrusive/unwanted thoughts
Flashbacks
Excessive Energy
Obsessive thoughts
Other
Substance Abuse History - Have you ever considered yourself to have a problem with alcohol or drugs?
Yes
No
Please list substance use including substance type and frequency of use.
Do you have any medication allergies or known allergies?
Yes
No
Not Sure
Please list them.
Do you have any metal objects or implantable devices in or around the head (e.g., cardiac defibrillator/pacemaker, insulin pump).
Yes
No
Unsure
If yes, please list Medical objects.
Medical Diagnosis?
Yes
No
If yes, specify medical diagnosis?
Recent surgeries?
Yes
No
If yes, specify recent surgeries:
Back
Next
Medication (past and present)
Check all medication tried.
Antidepressants: (From the list below, please check both current and previous medications tried).
Prozac (fluoxetine) - SSRI
Luvox (fluvoxamine) - SSRI
Celexa (citalopram) - SSRI
Effexor (venlafaxine) - SNRI
Tofranil (imipramine) - TCA
Vivactil (protriptyline) - TCA
Emsam (selegiline) - MAOI
Nardil (penelzine) - MAOI
Pristiq (desveniaflaxine) - SNRI
Wellbutrin (bupropion) - NDRI
Viibryd (vilazodone) - SM
Oleptro (Trazodone) - SM
Pamelor (nortriptyline) - TCA
Zoloft (sertraline) - SSRI
Paxil (Paroxetine) - SSRI
Lexapro (Escitalopram) - SSRI
Fetzima (levomilnacipran) - SNRI
Elavil (amitriptylie) - TCA
Remeron (mirtazapine) - TeCA
Marplan (isocarboxazid) - MAOI
Parnate (traylcpromine) - MAOI
Cymbalta (duloxetine) - SNRI
Serzone (nefazodone) - SM
Trintellix (vortioxetine) - SM
Anafranil (clomipramine) - TCA
Other
Mood stabilizers
Tegretol (carbamazepine)
Depakote (valproate)
Trileptal (oxcarbamazepine)
Lithium
Lamictal (lamotrigine)
Topamax (topiramate)
Other
Anti-psychotics / Mood stabilizers
Seroquel (quetiapine)
Abilify (aripiprazole)
Clozaril (clozapine)
Prolixin (fluphenazine)
Latuda (lurasidone)
Rexulti (brexpiprazule)
Geodon (olanzapine)
Zyprexa (olanzepine)
Haldol (haloperidol)
Risperdal (risperidone)
Invega (paliperidone)
Other
Sedative / Hypnotics
Ambien (zolpidem)
Rozerem (ramelteon)
Desyrel (trazodone)
Sonata (zaleplon)
Restoril (temazepam)
Other
ADHD / Stimulants:
Adderall (amphetamine)
Strattera (atomoxetine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Vyvanse (dextroamphetamine)
Other
Anti-Anxiety Medications
Xanax (alprazolam)
Klonopin (clonazepam)
Tranxene (clorazepate)
Ativan (lorazepam)
Valium (diazepam)
Buspar (buspirone)
Other
Please specify which medications you are currently taking at this time:
List only the medications you are currently prescribed and taking at this time. Please indicate dose and frequency.
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Journey Healthcare harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.*
*
Yes
Submit
Should be Empty: