WELCOME TO ALIGN - Patient History Form
Thank you for your interest to join the ALIGN Family. We are eager to assist you in aligning your mental health goals with your reality while meeting you where you are through Telehealth. Please complete our history form at least 24 hours prior to your scheduled appointment. If this has not been received, your appointment may be rescheduled.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
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Psychiatric Presentation
Please provide information about your current psychiatric presentation.
Please explain why you are currently seeking services
Are you experiencing any of the following? (Check all that apply)
Auditory Hallucinations (Hearing Things)
Decreased Appetite
Decreased functioning at one or more: Home, Work, School
Difficulty Focusing or Concentrating
Financial Instability
Homicidal Thoughts
Hypersomnia (Sleeping to much)
Increased Anxiety
Increased Appetite
Increased Depression
Insomnia (Cannot sleep)
Irritability/Anger
Low Interest in Activity
Low Motivation
Mood Lability
Paranoia (I.E. people are out to get you, people are listening to your conversations)
Racing Thoughts
Self-Harm
Suicidal Thoughts
Unstable Housing
Visual Hallucinations (Seeing Things)
Other
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Psychiatric History
Please provide information about your psychiatric history
Have you seen a psychiatric provider before?
Yes
No
Please list previous mental health diagnosis/conditions that have been diagnosed by a MENTAL HEALTH PROFESSIONAL.
Yes
No
ADHD
Autism/Aspergers
Bipolar Disorder (Manic-Depressive) Disorder)
Borderline Personality Disorder
Conduct Disorder
Generalized Anxiety Disorder
Insomnia
Major Depressive Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Panic Disorder
Psychosis
PTSD
Schizoaffective Disorder
Schizophrenia
Have you ever been admitted into a psychiatric hospital?
Yes
No
If you answered yes to the previous question, please explain in detail, how many times and hospital names. (N/A If Not Applicable)
Do you have a history of suicide attempts or self-harm?
Yes
No
If you answered yes to the previous question, please explain in detail, how many times and your actions. (N/A If Not Applicable)
Do you have any family with a history of mental health conditions? Please list.
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Psychiatric Medications
Are you currently taking any psychiatric medications?
Yes
No
If so, please list below. (Type N/A if you have never taken a psychiatric medication)
Psychiatric Medication Trials: Have you ever been on any of the following antidepressants, if so please check all the apply
Amitriptyline (Elavil)
Buproprion (Wellbutrin)
Citalopram (Celexa)
Clomipramine (Anafranil)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Fluoxetine (Prozax)
Fluvoxamine (Luvox)
Mirtazapine (Remeron)
Nortriptyline (Pamelor)
Paroxetine (Paxil)
Sertraline (Zoloft)
Trazodone (Desyrel)
Venlafaxine (Effexor)
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following anti-anxiety agents, if so please check all the apply
Alprazolam (Xanax)
Buspirone (Buspar)
Clonazepam (Klonopin)
Diazepam (Valium)
Gabapentin (Neurontin)
Hydroxyzine HCL (Atarax)
Hydroxyzine Pamoate (Vistaril)
Lorazepam (Ativan)
Propranolol (Inderal)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following mood stabilizers, if so please check all the apply
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Lithium
Oxcarbazepine (Trileptal)
Topiramate (Topamax)
Valproate (Depakote)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following anti-psychotics, if so please check all the apply
Aripiprazole (Abilify)
Asenapine (Saphris)
Cariprazine (Vraylar)
Chlorpromazine (Thorazine)
Clozapine (Clozaril)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following treatments for ADHD, if so please check all the apply
Amphehtamine Salts (Adderall)
Atomoxetine (Strattera)
Clonidine (Catapres)
Guanfacine (Intuniv)
Lisdexamfetamine (Vyvanse)
Methylphenidate (Adhansia XR)
Methylphenidate (Concerta)
Methylphenidate (Ritalin)
N/A
Other
Psychiatric Medication Trials: Have you ever been on any of the following sedative/hypnotics, if so please check all the apply
Doxepin (Silenor)
Eszopiclone (Lunesta)
Zolpidem (Ambien)
Quetiapine (Seroquel)
Ramelteon (Rozerem)
Suvorexant (Belsomra)
Temazepam (Restoril)
Trazodone (Desyrel)
N/A
Other
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Medical History
Who is your Primary Care Provider? (N/A if you do not have one)
When was the last time you had a wellness exam? (N/A if you have not had one within the last year or if unknown)
Please list any medical conditions, diseases, and surgeries that you have or have had. (I.E. asthma, diabetes, hepatitis C, herpes, hysterectomy)
Please list any allergies to food and/or drugs.
How tall are you?
How much do you weigh?
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Psychosocial History
Where were you born?
Who raised you?
How many siblings do you have?
What is your Highest Level of Education?
Are you currently employed? If so, where do you work and what do you do. If you are on disability please provide condition(s) you are receiving disability for.
Sexual Orientation
Asexual
Bisexual
Heterosexual
Homosexual
Pansexual
Do you have any children? How many?
Where and with whom do you live?
Do you have any current legal charges pending?
Yes
No
Have you ever been in the military?
Yes
No
Do you have history of trauma/abuse?
Yes
No
Domestic Violence
Emotional Abuse
Neglect
Physical Abuse
Sexual Abuse
Traumatic Incident in your Life
Traumatic Loss of Individuals
Verbal Abuse
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Substance Use History
Substance Use
Current Use
History of Use
Never Used
Alcohol
Amphetamines
Barbituates
Benzodiazepine
Caffeine
Cocaine
Hallucinogens
Inhalants
Marijuana
Nicotene
Opiates
PCP
Other
Other Substances. Please Explain
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Current Psychiatric Assessments
In the past 2 weeks, how often have they been bothered by the following:
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way
If you had to rate your mood (how happy or sad you are) in the past week, what would you rate it?
Worst
0
1
2
3
4
5
6
7
8
9
Best
10
0 is Worst, 10 is Best
In the past 2 weeks, how often have they been bothered by the following:
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
If you had to rate your anxiety in the past week, what would you rate it?
None
0
1
2
3
4
5
6
7
8
9
Worst
10
0 is None, 10 is Worst
Has there ever been a period of time when you were not your usual self and...
Yes
No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?3
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
Problem
No Problem
Minor Problem
Moderate Problem
Serious Problem
How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?
History of Manic-Depressive Illness or Bipolar
Yes
No
Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
Pharmacy
What pharmacy would you like to use? Please provide name and address.
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