INTAKE QUESTIONAIRE for Dr Eilis Clark MD Psychiatrist

INTAKE QUESTIONAIRE for Dr Eilis Clark MD Psychiatrist

Last Name:______First Name ______Date of Birth: ______

Address______City______State______Zip______

Mobile Phone______Home Phone ______Email______

Emergency Contact Name______Phone______Relation______

The first session can be expected to take about 1 hour, and there is a lot of information to cover, so the doctor may need to be a bit more directive than usual in order to find out the information she needs to best help you.

The first session is to evaluate whether we can help you, as well as for you to decide if you would like our help. Sometimes, we may not be able to have you as a patient, due to conflict of interest. Often, due to privacy issues involving others, we cannot give specific details about the conflict of interest.

Please do not expect to have medication prescribed at the first visit, particularly benzodiazepines (Xanax, Klonopin, Valium, Ativan, etc.) or stimulants (Ritalin,Adderall etc.). Before prescribing controlled substances, it is our policy to check the Florida Prescription Drug Monitoring Program database, as well as obtain or evaluate records from previous prescribers.

Eilis Clark MD LLC does not accept insurance, Medicaid or Medicare.

If your insurance allows out-of-network benefits, you will be provided with a billing form that you can submit to your insurance, and they might reimburse you partially.

Eilis Clark MD has chosen to opt-out of Medicare. Medicare will not pay for treatment by Eilis Clark MD, so this is the responsibility of the patient. This also means a patient with Medicare will need to sign a private contract agreeing not to submit a claim to Medicare, before the visit begins.

Who all do you live with? ______

Marital Status: ______Employment Status: ______Current/Last Job: ______

Please indicate what diagnoses you have been given previously:

□Major Depression □Dysthmia□Bipolar Disorder/ Manic Depression

□Anxiety Disorder □Panic Disorder □PTSD□ OCD

□Schizophrenia □Schizoaffective Disorder □Psychotic Disorder

□Alcohol Abuse/Dependence □Substance Abuse/Dependence □Personality Disorder

□Impulse Control Disorder □Eating Disorder □Other: ______

How many times have you been hospitalized for psychiatric issues? ______

How many times have you tried to kill yourself? ______

Have you damaged property or people in anger; describe? ______

Do you have firearms at your home? ______If yes, are they secured? ______

Have you experienced head injury with loss of consciousness? ______Or seizures? ______

Tobacco use use daily? ______If you do not use tobacco, did you ever? _____

How much alcohol do you use? ______

Have you ever had DTs or seizures from alcohol withdrawal? ______

Which of the following have you regularly used: Marijuana Cocaine Speed Heroin Other:_____

Last recreational drug use: ______Drug of Choice: ______

Trauma History (experienced/witnessed life-threatening injury, sexual violence, death):

Have you been sexually assaulted as an adult? _____ Physically assaulted as an adult? ______

Were you physically abused as a child? _____ Sexually abused as a child? ______

OtherLife-Threatening or Violent Traumatic Events: ______

Has anyone in your family killed themselves? ______

What psychiatric conditions run in your family (blood relatives)? ______

What alcohol or drug abuse conditions run in your family (blood relatives)? ______

What medical conditions run in your family? ______

Who raised you? ______How many siblings did you have? ______

How far did you get in school? ______

What kind of work have you done?______

How many times have you been married? ______How many kids do you have: ______

What legal problems have you had (DUI, PI, arrests, incarceration)? ______

Military Service: Branch: ______What years did you serve? _____ to _____ Combat? ____

I M P O R T A N T !

Please CHECK any PSYCHIATRIC MEDICINES youhave taken before:

□Celexa/citalopram □Lexapro/escitalopram □Prozac/fluoxetine □Luvox/fluvoxamine □Paxil/paroxetine □Zoloft/sertraline

□Effexor/venlafaxine □Pritiq/desvenlafaxine □Cymbalta/duloxetine □Fetzima/ levomilnacipram □Savella/milnacipran

□Wellbutrin/bupropion □Remeron/mirtazapine □Serzone/nefazodone □Desyrl/trazodone

□Viibryd/vilazodone□Trintellix/vortioxene

□Elavil/amitriptyline □Tofranil/imipramine □Anafranil/clomipramine □Sinequan/Silenor/doxepin□Surmontil/trimipramine □Ascendin/amoxapine □Norpramin/desipramine □Pamelor/nortriptyline □Vivactil/protriptyline □Ludiomil/maprotiline

□Nardil/phenelzine □Parnate/tranylcypromine □Marplan/isocarboxacid□Emsam/Eldepryl/seligiline

□Xanax/alprazolam □Klonopin/clonazepam □Librium/chlordiazepoxide □Tranxene/clorazepate □Valium/diazepam □ProSom/estazolam □Ativan/lorazepam□ Serax/oxazepam □Restoril/temazepam □Halcion/triazolam

□Buspar/buspirone

□Ambien/zolpidem □Sonata/zaleplon □Lunesta/eszopiclone □Rozarem/ramelteon □Belsomra/suvorexant

□Hydroxyzine/Vistaril □Diphenhydramine/Benadryl □Catapress/clonidine □Minipress/prazosin □Inderal/propranolol

□Eskalith/Lithobid/lithium □Divalproex/Depakene/valproate □Tegretol/Equetro/carbamazepine □Lamictal/lamotrigine Topamax/topirimate□Trileptal/oxycarbamazepine□Neurontin/gabapentin □Gabatril/tiagabine □Lyrica/pregabalin □Keppra/levetiracetam

□Prolixin/fluphenazine □Haldol/haloperidol □Trilafon/perphenazine □Orap/pimozide □Navane/thiothixene □Stelazine/trifluoperazine □Loxapin/loxitane□Moban/molindone □Serentil/mesoridazine □Thorazine/chlorpromazine □Mellaril/thioridazine

□Abilify/aripiprazole □Saphris/asenapine□Rexulti/brexipiprazole□Vraylar/carisprazine□Fanapt/iloperidone □Latuda/lurisadone□Zyprexa/olanzapine □Invega/paliperadone□Seroquel/quetiapine □Risperdal/risperidone □Geodon/Ziprasidone

□Antabuse/disulfiram □Revia/naltrexone □Campral/acamprosate□methadone □suboxone□Chantix/varenicline

□Aricept/donepezil □Razadyne/galantamine □Exelon/rivastigmine □Namenda/memantine

□Strattera/atomoxetine □Adderall/Dexedrine/Vynase/amphetamine □Ritalin/Concerta/Metadate/Focalin/Daytrana/methylphenidate □Provigil/modafinil □Nuvigil/armodafinil

□Qsymia □Belviq □Contrave □Saxenda □Orlistat/Alli □phentermine

□Cogentin/benztropine □Artane/trihexyphenidyl □Mirapex/pramipexole □Requip/ropinrole□Rilutek/riluzole□amantadine

□Zofran/ondansetron □Sancuso/granisetron □St John’s Wort □SAMe □Kava Kava □Valerian □Melatonin □Lavender □N-Acetyl-Cysteine □ACTIVATED B vitamins □ketamine

Please list anything memorable about the medicines on the previous page (what helped, what had side effects, etc.):

______

PLEASE INDICATE ANY OF THE FOLLOWING MEDICAL CONDITIONS YOU HAVE HAD:

(352)631-7460

□High Blood Pressure
□High Cholesterol
□Diabetes
□Heart Disease
□Stroke
□Head Injury
□Seizures
□Migraines
□Thyroid Disease
□Sleep Apnea
□Other: ______
□Other: ______/ □Arthritis
□Chronic Pain
□Renal/Kidney Disease
□Liver Disease
□Heartburn/GERD
□Restless Legs
□Fibromyalgia
□Chronic Fatigue
□Cancer
□Glaucoma
□Other: ______
□Other: ______

(352)631-7460

Please list any drug or food ALLERGIES: ______

CURRENT WEIGHT: ______CURRENT HEIGHT: ______

HANDEDNESS: RIGHT LEFT AMBIDEXTROUS (equally right & left)

CURRENT MEDICATIONS, OTC MEDICATIONS, VITAMINS, HERBS SUPPLEMENTS:

MEDICATION / DOSE / HOW OFTEN? / REASON/CONDITION

For women:Are you currently pregnant?□ Yes □No Are you currently breast feeding? □Yes □No

Are you considering pregnancy? □Yes □No Are you menopausal? □Yes □No

ReviewofSystems Checklist:(Pleasecheck any that you have had in the LAST 2 WEEKS)

Constitutional:□weightloss□weightgain□fatigue□generalweakness□fever

Eye:□visualchanges□eyepain□doublevision□blurryvision□flashinglights

Ears/Nose/Throat:□runnynose□stuffynose□frequentnosebleeds□stuffyears□earpain

□ringinginears□hearingloss

Cardiovascular:□chestpain□exerciseintolerance□palpitations□faintness

□Lightheadednessuponstanding

Respiratory:□cough□sputum□wheeze□shortnessofbreath

Gastrointestinal:□abdominalpain□difficultyswallowing□nausea□vomiting□bloodystools

□blacktarrystools□heartburn□yelloweyesorskin□diarrhea□constipation

Genitourinary:□Urinaryincontinence□pain□nighturination□hesitancy□bloodyurine

□troublereachingorgasm □lowsexdrive

Female:□menopause□hotflashes□vaginaldischarge□heavymenses

Male: □painwithsex□erectiledysfunction

Musculoskeletal:□falls□musclepain□stiffness□jointswelling□jointpain□arthritis□backpain

Skin/Breast:□itching□rashes□excessivedryness□hairloss□breastpainordischarge

Neurologic:□limbweakness□seizures□fainting□headache□pinsneedles□numbness□imbalance

□speechproblems□dizziness□tremor

Endocrine:□sweaty□excessivethirst□excessiveamountsofurine□heatorcoldintolerance

Female:□irregularperiods

BloodSystem:□anemia□excessivebleeding□easybruising

Immunologic:□recurrentinfections□allergicreactions□swellingoflymphnodes

PHQ-9 Over the last 2 weeks, how often have you been bothered by any of the following problems?
1 Little interest or pleasure in doing things / □Not at all / □Several days / □More than half the days / □Nearly every day
2 Feeling down, depressed or hopeless / □Not at all / □Several days / □More than half the days / □Nearly every day
3 Trouble falling or staying asleep, or
sleeping too much / □Not at all / □Several days / □More than half the days / □Nearly every day
4 Feeling tired or having little energy / □Not at all / □Several days / □More than half the days / □Nearly every day
5 Poor appetite or overeating / □Not at all / □Several days / □More than half the days / □Nearly every day
6 Feeling bad about yourself – or that you have let yourself or your family down / □Not at all / □Several days / □More than half the days / □Nearly every day
7 Trouble concentrating on things, such as reading the newspaper or watching television / □Not at all / □Several days / □More than half the days / □Nearly every day
8 Moving so slowly that other people noticed? Or
the opposite – being so fidgety or restless that you have been moving around a lot more than usual / □Not at all / □Several days / □More than half the days / □Nearly every day
9 Thoughts that you would be better off dead or
of hurting yourself in some way / □Not at all / □Several days / □More than half the days / □Nearly every day
GAD7 Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous anxiety or on edge on most days / □Not at all / □Several days / □More than half the days / □Nearly every day
2. Not being able to stop or control worryingon most days / □Not at all / □Several days / □More than half the days / □Nearly every day
3. Worrying too much about different things on most days / □Not at all / □Several days / □More than half the days / □Nearly every day
4. Trouble relaxing because you were worrying / □Not at all / □Several days / □More than half the days / □Nearly every day
5. Being so restless that it is hard to sit still because you were worrying / □Not at all / □Several days / □More than half the days / □Nearly every day
6. Becoming easily annoyed or irritable because you were worried/stressed / □Not at all / □Several days / □More than half the days / □Nearly every day
7. Feeling afraid as if something awful might happen / □Not at all / □Several days / □More than half the days / □Nearly every day
Tiring easily because of worrying / □No / □Yes
Mind blanking/difficulty concentrating because your mind is on your worries / □No / □Yes
Tension in your muscles because of anxiety or stress / □No / □Yes
Problems falling asleep because you are worrying about things / □No / □Yes

If you have NOT experienced any traumatic events, please check here □and skip to the next section (Mood Check).

PCL-5 Instructions: This questionnaire asks about problems you may have had after a very stressful experience involving actual or threatened death, serious injury, or sexual violence. It could be something that happened to you directly, something you witnessed, or something you learned happened to a close family member or close friend. Some examples are a serious accident; fire; disaster such as a hurricane, tornado, or earthquake; physical or sexual attack or abuse; war; homicide; or suicide.

First, please answer a few questions about your worst event, which for this questionnaire means the event that currently bothers you the most. This could be one of the examples above or some other very stressful experience. Also, it could be a single event (for example, a car crash) or multiple similar events (for example, multiple stressful events in a war-zone or repeated sexual abuse).

Briefly identify the worst event (if you feel comfortable doing so): ______

How long ago did it happen? ______(please estimate if you are not sure)

Did it involve actual or threatened death, serious injury, or sexual violence?

□Yes

□No

How did you experience it?

□It happened to me directly

□ I witnessed it

□ I learned about it happening to a close family member or close friend

□ I was repeatedly exposed to details about it as part of my job (for example, paramedic, police, military, or other first responder)

□Other, please describe ______

If the event involved the death of a close family member or close friend, was it due to some kind of accident or violence, or was it due to natural causes?

□Accident or violence

□Natural causes

□Not applicable (the event did not involve the death of a close family member or close friend)

Second, keeping this worst event in mind, read each of the problems on the next page and then check one of the numbers to indicate how much you have been bothered by that problem in the past month.

A little bit would be 1 – 2 days out of the month

Moderately would be 1 to 2 days a week

Quite a bit would be 3 to 4 days a week

Extremely would be daily or almost daily

In the past month, how much were you bothered by: / Not at all / A little bit / Moderately / Quite a bit / Extremely
1. Repeated, disturbing, and unwanted memories of the stressful experience? / □0 / □1 / □2 / □3 / □4
2. Repeated, disturbing dreams of the stressful experience? / □0 / □1 / □2 / □3 / □4
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? / □0 / □1 / □2 / □3 / □4
4. Feeling very upset when something reminded you of the stressful experience? / □0 / □1 / □2 / □3 / □4
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? / □0 / □1 / □2 / □3 / □4
6. Avoiding memories, thoughts, or feelings related to the stressful experience? / □0 / □1 / □2 / □3 / □4
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? / □0 / □1 / □2 / □3 / □4
8. Trouble remembering important parts of the stressful experience? / □0 / □1 / □2 / □3 / □4
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? / □0 / □1 / □2 / □3 / □4
10. Blaming yourself or someone else for the stressful experience or what happened after it? / □0 / □1 / □2 / □3 / □4
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? / □0 / □1 / □2 / □3 / □4
12. Loss of interest in activities that you used to enjoy? / □0 / □1 / □2 / □3 / □4
13. Feeling distant or cut off from other people? / □0 / □1 / □2 / □3 / □4
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? / □0 / □1 / □2 / □3 / □4
15. Irritable behavior, angry outbursts, or acting aggressively? / □0 / □1 / □2 / □3 / □4
16. Taking too many risks or doing things that could cause you harm? / □0 / □1 / □2 / □3 / □4
17. Being “superalert” or watchful or on guard? / □0 / □1 / □2 / □3 / □4
18. Feeling jumpy or easily startled? / □0 / □1 / □2 / □3 / □4
19. Having difficulty concentrating? / □0 / □1 / □2 / □3 / □4
20. Trouble falling or staying asleep? / □0 / □1 / □2 / □3 / □4

PCL-5 (8/14/2013) Weathers, Litz, Keane, Palmieri, Marx, & Schnurr -- National Center for PTSD

MoodCheck1. Please place a check in front of the statements below that accurately describe you.

During times when I am NOT using drugs or alcohol:
 / I notice that my mood and/or energy levels shift drastically from time to time.
 / At times, I am moody and/or energy level is very low, and at other times, and very high.
 / During my "low" phases, I often feel a lack of energy, a need to stay in bed or get extra sleep, and little or no motivation to do things I need to do.
 / I often put on weight during these periods.
 / During my low phases, I often feel "blue," sad all the time, or depressed.
 / Sometimes, during the low phases, I feel helpless or even suicidal.
 / During the low phases, my ability to function at work or socially is impaired.
 / Typically, the low phases last for a few weeks, but sometimes they last only a few days.
 / I also experience a period of "normal" mood in between mood swings, during which
my mood and energy level feels "right" and my ability to function is not disturbed.
 / I then notice a marked shift or "switch" in the way I feel.
 / My energy increases above what is normal for me, and I often get many things done
I would not ordinarily be able to do.
 / Sometimes during those "high" periods, I feel as if I have too much energy or feel "hyper".
 / During these high periods, I may feel irritable, "on edge," or aggressive.
 / During the high periods, I may take on too many activities at once.
 / During the high periods, I may spend money in ways that cause me trouble.
 / I may be more talkative, outgoing or sexual during these periods.
 / Sometimes, my behavior during the high periods seems strange or annoying to others.
 / Sometimes, I get into difficulty with co-workers or police during these high periods.
 / Sometimes, I increase my alcohol or nonprescription drug use during the high periods.

2. The statements above (not just those checked) describe me (check1 of the answers below):

Not at all 0 / A little 2 / Fairly well 4 / Very well 6

Adult Self-Report Scale (ASRS-v1.1) Symptom Checklist

Circle the number that best describes how you have felt and conducted yourself over the past 6 months.

Never / Rarely / Some-
times / Often / Very Often
1.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
2.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
3.How often do you have problems remembering appointments or obligations? / □0 / □1 / □2 / □3 / □4
4.When you have a task that requires a lot of thought, how often do you avoid or delay getting started? / □0 / □1 / □2 / □3 / □4
5.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
6.How often do you feel overly active and compelled to do things, like you were driven by a motor? / □0 / □1 / □2 / □3 / □4
7.How often do you make careless mistakes when you have to work on a boring or difficult project? / □0 / □1 / □2 / □3 / □4
8.How often do you have difficulty keeping your attention when you are doing boring or repetitive work? / □0 / □1 / □2 / □3 / □4
9.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
10.How often do you misplace of have difficulty finding things at home or at work? / □0 / □1 / □2 / □3 / □4
11.How often are you distracted by activity or noise around you? / □0 / □1 / □2 / □3 / □4
12.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
13.How often do you feel restless or fidgety? / □0 / □1 / □2 / □3 / □4
14.How often do you have difficulty unwinding and relaxing when you have time to yourself? / □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