– 1 –August 8, 2007
Robert I. Picker, M.D.
Diplomate in Psychiatry,
American Board of Psychiatry and Neurology
The SanMarcoBuilding
1399 Ygnacio Valley Rd., Suite 25
Walnut Creek, CA94598
Tel.: (925) 945-8440
Fax: (925) 945-8448
Initial Psychiatric Evaluation
Date:
Name:
Address:
Tel.:
FAX:
Email address:
Date of Birth:
Who referred you to Dr. Picker?
PRESENTING PROBLEM
Please describe your primary psychiatric problem:
When did this problem start?
Any ideas what brought it on?
Are your currently receiving any treatment for this problem? What sort of treatment and from whom?
PAST PSYCHIATRIC HISTORY
What previous treatment you received for this problem?
Psychotherapy? When/where/with whom?
Psychiatric treatment? When/where/with whom?
Please list medications you can remember trying in the past for psychiatric problems, with what results? (If you can remember the benefits and/or reasons for stopping each of those medications it would be very helpful.)
Medication / Dose / # doses per day / Estimated start date / Estimated stop date / Results?If stopped, why?
Any history of suicide attempts? Was this attempt disclosed to others?
Did it result in emergency treatment or hospitalization? Where? When?
Have you been the victim of violence or abuse? By whom? When?
Have you been violent vs. another person? Circumstances?
Have you ever been incarcerated? When, why and for how long?
Are there any pending legal actions against you, including a DUI by the
DMV?
Any DUI convictions in the past? When? Where? What for? Resolution?
Medical History:
Primary Care Physician:
Allergies:
Hospitalizations:
Surgery:
Women: OB-GYN history:
Number of pregnancies ______
Number of deliveries ______
Any complications?
Current Medical Illness:
Diagnoses?
Treatment?
Please list all medications which you are currently taking for medical problems (including over-the-counter and herbal remedies, as well as nutritional supplements):
Current Medications (non-psychiatric):
Medication dose (mg.) times per day What for? Since when? Prescriber?
Social History:
Current living situation (how many in household?):
Sexual orientation:
Marital status (current):
# Marriages (approx. dates):
#Divorces:
Children: Boys (age):
Girls (age):
Employment status:
Work type:
Employer:
Full time or part time?
Disability:
Education History
How far did you get in school?
Degrees? From where?
Other relevant factors:
Family History:
Please note any pertinent issues with physical or mental health in your relatives.
Father:
Alive or deceased?______
Health problems? ______
Mental health problems/treatment (whether diagnosed or not)?
______
Substance abuse problems?______
History of violence or abuse? ______
Mother:
Alive or deceased?______
Health problems? ______
Mental health problems/treatment (whether diagnosed or not)?
______
Substance abuse problems?______
History of violence or abuse? ______
Siblings (#brothers/sisters)
Alive or deceased?______
Health problems? ______
Mental health problems/treatment (whether diagnosed or not)?
______
Substance abuse problems?______
History of violence or abuse? ______
Aunts/uncles:
Alive or deceased?______
Health problems? ______
Mental health problems/treatment (whether diagnosed or not)?
______
Substance abuse problems?______
History of violence or abuse? ______
Children:
Health problems? ______
Mental health problems/treatment (whether diagnosed or not)?
______
Substance abuse problems?______
History of violence or abuse? ______
Review of Psychiatric Symptoms
MINI PATIENT HEALTH SURVEY
Panic Attacks
1.Have you, on more than one occasion, had spells or attacks when you suddenly
felt anxious, frightened, uncomfortable or uneasy, even in situations where mostpeople would not feel that way? Did the spells peak within 10 minutes?
□ yes □ no
2.At any time in the past, did any of those spells or attacks come on unexpectedl or occur in an unpredictable or unprovoked manner? □ yes □ no
3.Have you ever had one such attack followed by a month or more of persistent fear ofhaving another attack, or worries about the consequences of the attack?
□ yes □ no
4.During the worst spell that you can remember:
a.Did you have skipping, racing or pounding of your heart? □ yes □ no
b.Did you have sweaty or clammy hands?
c.Were you trembling or shaking? □ yes □ no
d.Did you have shortness of breath or difficulty breathing?
□ yes □ no
e.Did you have a choking sensation or a lump in your throat?
□ yes □ no
f.Did you have chest pain, pressure or discomfort?
□ yes □ no
g.Did you have nausea, stomach problems or sudden diarrhea? □ yes □ no
h.Did you feel dizzy, unsteady, lightheaded or faint? □ yes □ no
i.Did you feel that you were losing control or going crazy? □ yes □ no
j.Did you fear that you were dying? □ yes □ no
k.Did you have tingling or numbness in parts of your body? □ yes □ no
l.Did you have hot flushes or chills? □ yes □ no
- In the past month, did you have such attacks repeatedly (2 or more) followed bypersistentfear of having another attack? □ yes □ no
Social Anxiety Disorder
- In the past month, were you fearful of or embarrassed by being watched or being the focusof attention, or fearful of being humiliated? This includes things like speakingin public, eating in public alone or with other, writing while someone watches, or being in social situations? □ yes □ no
2.Is this fear excessive or unreasonable? □ yes □ no
3.Do you fear these situations so much that you avoid them or suffer through them? □ yes □ no
4.Does this fear disrupt your normal work or social functioning or cause you
significant distress? □ yes □ no
Depression
- Have you been consistently depressed or down, most of the day, nearly every day, for the past two weeks? □ yes □ no
2.In the past two weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of the time?
□ yes □ no
3.Over the past two weeks, when you felt depressed on uninterested:
a.Was your appetite decreased or increased nearly every day? Did your weight
decrease or increase without trying intentionally (i.e. ± 5% of body weight or ±
8 lbs. or ± 3.5 kg. for a 160 lb./70 kg. person in a month?)
If yes to either,please check “YES”.
□ yes □ no
b. Did you have trouble sleeping nearly every night (difficulty falling asleep,
wakingup in the middle of the night, early morning wakening or sleeping
excessively? □ yes □ no
c.Did you talk or move more slowly than normal or were you fidgety,
restlessorhaving trouble sitting still most of the day? □ yes □ no
d.Did you feel tired or without energy almost every day? □ yes □ no
e.Did you feel worthless or guilty almost every day? □ yes □ no
f.Did you have difficulty concentrating or making decisions almost every
day? □ yes □ no
g.Did you repeatedly consider hurting yourself, feel suicidal, or wish that
you weredead? □ yes □ no
- In the past 12 months, have you had 3 or more alcoholic drinks within a 3-hour period on 3 or more occasions? □ yes □ no
2.In the past 12 months:
a.Did you need to drink more in order to get the same effect that you got
when youfirst started drinking? □ yes □ no
b.When you cut down on drinking did your hands shake, did you sweat or
feelagitated? □ yes □ no
c.During the times when you drank alcohol, did you end up drinking more thanyou planned when you started? □ yes □ no
d. Have you tried to reduce or stop drinking alcohol but failed?
□ yes □ no
e.On the days that you drank, did you spend substantial time in obtaining
alcohol drinking, or in recovering from the effects of alcohol?
□ yes □ no
f.Did you spend less time working, enjoying hobbies, or being with others
because of your drinking? □ yes □ no
g.Have you continued to drink even though you knew that it caused youproblems? □ yes □ no
Mood Disorder Questionnaire
Instructions: Please answer each question as best you can.
1.Has there ever been a period of time when you were not your usual self and
you felt so good or so hyper that other people thought you were not your normal
self or your were so hyper that you got into trouble? □ yes □ no
---you were so irritable that you shouted at people or started fights or arguments? □ yes □ no
---you felt much more self-confident than usual? □ yes □ no
---you got much less sleep than usual and found you didn’t really miss it? □ yes □ no
---you were much more talkative or spoke much faster than usual? □ yes □ no
---thoughts raced through your head or you couldn’t slow your mind down? □ yes □ no
---you were so easily distracted by things around you that you had trouble
concentrating or staying on track? □ yes □ no
---you had much more energy than usual? □ yes □ no
---you were much more active or did many more things than usual? □ yes □ no
---you were much more social or outgoing than usual – for example you telephoned friends in the middle of the night? □ yes □ no
---you were much more interested in sex that usual? □ yes □ no
---you did things that were unusual for you or that other people might have thought were excessive, foolish or risky? □ yes □ no
---spending money got you or your family into trouble?□ yes □ no
- If you checked “YES” to more than one of the above, have several of these ever
happened during the same period of time? □ yes □ no
3. How much of a problem did any of these cause you?
Being unable to work-
No problem □ Minor Problem □ Moderate Problem □ Serious Problem □
Having family,money or legal troubles-
No problem □ Minor Problem □ Moderate Problem □ Serious Problem □
Getting into arguments or fights?
No problem □ Minor Problem □ Moderate Problem □ Serious Problem □
No problem □ Minor Problem □ Moderate Problem □ Serious Problem □
4.Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
□ yes □ no
5.Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? □ yes □ no
Adult Self-Report Scale (ASRS) Symptom ChecklistPatient Name / Today's Date
Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, circle the correct number that best describes how you have felt and conducted yourself over the past 6 months. Please give the completed checklist to your healthcare professional to discuss during today's appointment. / Never / Rarely / Sometimes / Often / Very
Often / Score
1. How often do you make careless mistakes when you have to work on a boring or difficult project? / 0 / 1 / 2 / 3 / 4
2. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? / 0 / 1 / 2 / 3 / 4
3. How often do you have difficulty concentrating on what people say to you even when they are speaking to you directly? / 0 / 1 / 2 / 3 / 4
4. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? / 0 / 1 / 2 / 3 / 4
5. How often do you have difficulty getting things in order when you have to do a task that requires organization? / 0 / 1 / 2 / 3 / 4
6. When you have a task that requires a lot of thought, how often do you avoid or delay getting starting? / 0 / 1 / 2 / 3 / 4
7. How often do you misplace or have diffficulty finding things at home or at work? / 0 / 1 / 2 / 3 / 4
8. How often are you distracted by activity or noise around you? / 0 / 1 / 2 / 3 / 4
9. How often do you have problems remembering appointments or obligations? / 0 / 1 / 2 / 3 / 4
Part A - Total
10. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? / 0 / 1 / 2 / 3 / 4
11. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? / 0 / 1 / 2 / 3 / 4
12. How often do you feel restless or fidgety? / 0 / 1 / 2 / 3 / 4
13. How often do you have difficulty unwinding and relaxing when you have time to yourself? / 0 / 1 / 2 / 3 / 4
14. How often do you feel overly active and compelled to do things, like you were driven by a motor? / 0 / 1 / 2 / 3 / 4
15. How often do you find yourself talking too much when you are in social situations? / 0 / 1 / 2 / 3 / 4
16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? / 0 / 1 / 2 / 3 / 4
17. How often do you have difficulty waiting your turn in situations when turn taking is required? / 0 / 1 / 2 / 3 / 4
18. How often do you interrupt others when they are busy? / 0 / 1 / 2 / 3 / 4
Part B - Total