Victoria Martin, M.D.
New Patient Enrollment - Adults (18 and older)
Patient's Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
Birth Sex
*
Please Select
Female
Male
Intersex
Prefer not to respond
Gender Identity
Please Select
Woman
Man
Transgender
Non-binary/non-conforming
Prefer not to respond
Contact Number:
*
Secondary Number:
E-mail
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In case of emergency
Emergency Contact:
First Name
Last Name
Relationship
Contact Number
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Developmental and Social History
Adults
What is your current age?
Where were you raised?
Were you adopted?
Yes
No
Give details of your adoption and any relationship with biological family:
List your brothers and sisters and their ages:
Mother's occupation:
Father's occupation:
Did your parents divorce?
Yes
No
How old were you when they separated?
How old were you when your mother remarried?
How old were you when your father remarried?
Describe your mother and your relationship with her:
Describe your father and your relationship with him:
How old is your mother currently?
How old is your father currently?
How old were you when you left home?
Has anyone in your immediate family died?
Yes
No
Who and when?
Have you ever been physically or sexually abused?
Yes
No
At what age(s)?
By whom?
Marital Status
Please Select
Single
Long-term relationship
Married
Divorced
Legally separated
Widowed
How long in current status?
What is your significant other's occupation?
Describe your relationship with your significant other:
Have you had any previous marriages?
Yes
No
How many?
For how long, each?
Do you have any children?
Yes
No
Names and ages:
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Educational and Occupational History
Adults
Did you enjoy school?
What kind of grades did you make in school?
Describe your social life at school:
What kind of things got you in trouble at school?
Highest educational level or degree attained?
Please Select
Non-graduate
High School
College/Trade School
Post-graduate
List any certifications, titles or degrees you have:
Are you currently working?
Yes
No
Where do you work?
How long in current position?
What is your occupation?
Where have you worked before and for how long?
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Medical History
Adults
Who is your primary care physician?
When was your last appointment?
Do you have any ongoing medical conditions?
Yes
No
Please list any medical conditions:
Have you ever had surgery?
Yes
No
Please list any previous surgeries and date of procedures:
Have you ever experienced any heart problems?
Yes
No
Explain any previous/current heart problems:
Is there any possibility that you are pregnant?
Yes
No
Are you considering pregnancy?
Yes
No
Have you ever seen a psychiatrist?
Yes
No
Please list your previous psychiatrist(s) and dates seen:
Describe the treatment:
Have you ever seen a therapist?
Yes
No
Please list any current/previous therapists and dates seen:
Have you ever been hospitalized for a psychiatric episode?
Yes
No
Please describe the circumstances of the hospitalization(s) and dates of admission:
Are you taking any medications or vitamins, currently?
Yes
No
List all medications and vitamins with dosing:
Have you ever previously been prescribed medication? (not currently taking)
Yes
No
List all medications previously prescribed:
Are you allergic to any medications?
Yes
No
List all medications you are allergic to:
List any blood-relatives that have had a history of psychiatric or emotional problems:
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History with Substances
Adults
Do you smoke or vape cigarettes/nicotine?
Yes
No
How much?
How long?
Do you drink alcohol?
Yes
No
How often do you drink?
Please Select
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week
Have you ever felt you are drinking too much?
Yes
No
Have you ever tried unsuccessfully to stop drinking?
Yes
No
Have you ever used any recreational drugs?
Yes
No
Have you ever recreationally used any of the following? (check all that apply)
Cannabis (Marijuana/THC)
Benzos (Xanax/Klonopin)
Cocaine (Powder/Crack)
Heroin
Inhalants (Poppers/Whip-its)
Ketamine (Special K)
LSD (Acid)
MDMA (Ecstasy, Molly)
Mescaline (Peyote)
Methamphetamine (Crystal/Meth)
PCP (Angel Dust)
Prescription Opioids (Fentanyl/Oxy/Percs)
Prescription Stimulants (Speed, Adderall)
Psilocybin (Magic Mushrooms)
Synthetic Cannabinoids (K2/Spice)
Synthetic Cathinones (Bath Salts/Flakka)
Other
Other drugs:
Have you ever felt you had a problem with any of the above drugs?
Yes
No
Ellaborate:
Have you ever used drugs I.V.?
Yes
No
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Zung Depression Scale
Adults
For each of the following statements, select 1 of the 5 responses that best fit you. (All statements must be answered)
*
N/A
Little
Some
Often
Mostly
I feel down-hearted and blue.
Morning is when I feel the best.
I have crying spells or feel like it.
I have trouble sleeping at night.
I eat as much as I used to.
I still enjoy sex.
I notice that I am losing weight.
I have trouble with constipation.
My heart beats faster than usual.
I get tired for no reason.
My mind is as clear as it used to be.
I find it easy to do the things I used to.
I am restless and can't keep still.
I feel hopeful about the future.
I am more irritable than usual.
I find it easy to make decisions.
I feel that I am useful and needed.
My life is pretty full.
I feel that others would be better off if I were dead.
I still enjoy the things I used to do.
Office Use Only: Standard range (50-69)
In Range: YES
Out of Range: YES
Total:
Additional notes:
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ADHD Rating Scale
Adults
For each of the following statements, mark the box under "YES", "SOME" or "NO" depending upon which best fits you. (All statements must be answered)
*
Yes
Some
No
I fail to pay close attention to details or I tend to make careless mistakes.
I have difficulty sustaining attention.
I often find I have failed to listen or have read a paragraph and don't know what I have read.
I have difficulty finishing tasks, or I have multiple projects going at the same time.
I have difficulty organizing tasks and activities.
I often misplace or lose items.
I am easily distracted by extraneous stimuli.
I often seem forgetful or absent-minded, even regarding daily activities.
I often fidget with my hands and feet.
I feel "on the go" as if I am driven by a motor.
I interrupt conversation or blurt out answers before questions have been completed.
I am impatient and I have trouble waiting.
I feel that I have failed to accomplish what I'm capable of.
I procrastinate (put things off).
I am a risk taker.
I get bored easily.
I have a history of impulsive behavior.
I have frequent and dramatic mood swings.
I have difficulty settling down at night and going to sleep.
I struggle with low self-esteem.
Additional notes:
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Anxiety Rating Scale
Adults
For each of the following statements, select 1 of the 4 responses that best fits you. (All statements must be answered)
*
None
Little
Moderate
Severe
I have experienced palpitations, pounding heart or accelerated
heart rate.
I have experienced excessive sweating.
I have experienced trembling or shaking.
I have experienced sensations of shortness of breath or
smothering.
I have experienced a sensation of choking.
I have experienced chest pain or discomfort.
I have experienced nausea or abdominal distress.
I have felt dizzy, unsteady, lightheaded or faint.
I have experienced feelings of unreality or depersonalization
(feeling detached).
I have experienced fear of losing control or going crazy.
I have experienced fear of dying.
I have experienced numbness and/or tingling.
I have experienced chills or hot flashes.
I have experienced fear about being in places or situations
where escape might be difficult or embarrassing.
I have experienced recurrent and persistent thoughts that are
interpreted as intrusive and inappropriate, that cause marked
stress, and that are not simply excessive worries about real
life problems.
I engage in repetitive behaviors (e.g. hand washing, rechecking) or repetitive thoughts (e.g. counting, repeating
words) aimed at reducing stress, which is not connected in a
realistic way to the stress, which I aimed at reducing.
The behaviors mentioned in the above two questions are
stress producing or time consuming (taking more than one
hour per day) or interfere with my normal routine, occupation,
or social activities.
I have suffered from excessive anxiety more days than not for
at least 6 months about a number of events or activities.
I find it difficult to control anxiety.
I suffer from anxiety associated with restlessness, being easily tired, difficulty concentrating, irritability, muscle tension or sleep disturbance.
Anxiety interferes with my normal routine, occupation, or
social activities.
Additional notes:
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