Please Complete All Information on This Form and Bring It to the First Visit

Ruth Matheson ARNP

Please complete all information on this form and bring it to the first visit

CLIENT DEMOGRAPHIC INFORMATION

(PLEASE BE PREPARED TO HAVE A COPY OF IDENTIFICATION TAKEN AT FIRST APPOINTMENT)

Date ______

Name ______

Age _____Date of Birth ______

Gender______

Relationship status: ______

Occupational Status ______

Do you have a nickname or any other preferred name? ______

Address

______

Contact information:

Preferred number ______

OK to leave confidential message? yes/no

Alternative phone number ______

OK to leave confidential message either by voicemail or text? yes/no

Emergency contact: Name______

Relationship to you ______

Phone number (s) ______

OK to leave confidential message yes/no

INSURANCE/ BILLING INFORMATION

Insurance Information (PLEASE BE PREPARED TO HAVE A COPY TAKEN OF INSURANCE CARD AT FIRST APPOINTMENT)

Primary identification number ______

Group number ______

If this insurance is under someone other than you, what is the name of this person?

______

Person responsible for copayments, coinsurance, deductibles and/or payments in full:

Name ______

Relationship to client: ______

Social Security Number ______

Employer ______

Date of Birth______

Although this may take you some time, this information is important so that we can together develop a treatment plan that best meets your needs.

Are you self referred or were you referred by someone else?

___ self-referred

___ referred by someone else

Referred by______

Phone number______

Address ______

Please tell me what you would like to accomplish at today’s appointment. What are your goals for treatment?

______

Do you have people in your life that you consider supportive? Who are they? Who would you call if you were having an emergency?

______

Is there anything else that you would like me to know about you (such as your spiritual, religious, ethnic or cultural background)? ______

Anxiety Questionnaire

Over the last 2 weeks how often have you been bothered by any of the following problems?

Not at allSeveral DaysMore than half the daysNearly everyday

1. Feeling nervous, anxious or on edge. / 0 / 1 / 2 / 3
2. Not being able to stop or control worrying. / 0 / 1 / 2 / 3
3. Worrying too much about different things. / 0 / 1 / 2 / 3
4. Trouble relaxing / 0 / 1 / 2 / 3
5. Being so restless that it is hard to sit still. / 0 / 1 / 2 / 3
6. Becoming easily annoyed or irritable. / 0 / 1 / 2 / 3
7. Feeling afraid as if something awful might happen. / 0 / 1 / 2 / 3

TOTAL SCORE:______

If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home and get a long with other people? PLEASE CIRCLE ONE.

Not difficult at allSomewhat difficultVery difficult Extremely difficult

Depression Inventory (PHQ9)

Over the last 2 weeks how often have you been bothered by any of the following problems?

Not at allSeveral DaysMore than half the daysNearly everyday

1. Little interest or pleasure in doing things / 0 / 1 / 2 / 3
2. Feeling down, depressed, or hopeless / 0 / 1 / 2 / 3
3. Trouble falling or staying asleep or sleeping too much. / 0 / 1 / 2 / 3
4. Feeling tired or having little energy / 0 / 1 / 2 / 3
5. Poor appetite or overeating / 0 / 1 / 2 / 3
6. Feeling bad about yourself-or that you are a failure of have let yourself or family down / 0 / 1 / 2 / 3
7. Trouble concentrating on things, such as reading the newspaper or watching television / 0 / 1 / 2 / 3
8. Moving or speaking slowly that other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more usual. / 0 / 1 / 2 / 3
9. Thoughts that you would be better off dead or of hurting yourself in some way / 0 / 1 / 2 / 3

TOTAL SCORE:______

If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home and get a long with other people? PLEASE CIRCLE ONE.

Not difficult at allSomewhat difficultVery difficult Extremely difficult

Mood Disorder Questionnaire

1) You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you go into trouble?

2) You were so irritable that you shouted at people or started fights or arguments?

3) You felt so much more self-confident than usual?

4) You go much less sleep than usual and found you didn’t really miss it?

5) You were much more talkative or spoke much faster than usual?

6) Thoughts raced through your head or you couldn’t slow your mind down?

7) You were so easily distracted by things around you that you had trouble concentrating or staying on track?

8) You had much more energy than usual?

9) You were much more active or did many more things than usual?

10)You were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night?

11)You were much more interested in sex than usual?

12)You did things that were unusual for you or that other people might have though were excessive, foolish, or risky?

13)Spending money got you or your family in trouble?

14)If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

15)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? Please select response only.

No Problem
Minor Problem
Moderate Problem
Serious Problem

16)Have any of your blood relatives (children, siblings, parents, grand parents, aunts, uncles) had manic-depressive illness or bipolar disorder?

17)Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Psychiatric Hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where.

ReasonDate HospitalizedWhere ______

______

Past Psychiatric History Outpatient treatment (such as counseling, therapy, medication management

( ) Yes ( ) No If yes, Please describe when, by whom, and nature of treatment.

ReasonDates treatedBy whom ______

Have you ever tried to end your life? ( ) Yes ( ) No If yes, please provide details

______

Have you ever engaged in self-injurious behavior; such as cutting? ( ) Yes ( ) No

Alcohol/Substance Use:

Because alcohol and substances can interfere with certain medications and treatments, it is important that you are fill out this section completely. If you have NEVER used alcohol note this here ______

The Alcohol Use Disorders Identification Test

Circle the numbered answer that best fits you.

1. How often do you have a drink containing alcohol?

0. Never

Monthly or less
2-4 times a month
2-3 times a week

4. 4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

0. 1 or 2

3 or 4
5 or 6
7 to 9

4. 10 or more

3. How often do you have six or more drinks on one occasion?

0. Never

Less than monthly
Monthly
Weekly
Daily or almost daily

4. How often during the last year have you found that you were not able to stop drinking once you had started?

0. Never

1. Less than monthly

Monthly

3. Weekly

4 Daily or almost daily

5. How often during the last year have you failed to do what was normally expected of you because of drinking?

0. Never

1. Less than monthly

2. Monthly

3. Weekly

4. Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

0. Never

Less than monthly
Monthly
Weekly
Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

0. Never

Less than monthly
Monthly
Weekly
Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

0. Never

Less than monthly
Monthly
Weekly
Daily or almost daily

9. Have you or someone else been injured because of your drinking?

0. No

2. Yes, but not in the last year

4. Yes, during the last year

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

0. No

2. Yes, but not in the last year

4. Yes, during the last year

Total points _____ (add together circled numbers)

Do you think you may have a problem with alcohol or drug use? ( ) Yes ( ) No

If yes, please explain

______

Have you haveexperimented or used street drugs in the past? ( ) Yes ( ) No If yes, which ones? Any IV drug use? When was your last use?

______

Have you abused prescription medication? ( ) Yes ( ) No If yes, which ones when and for how long? l______

Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No ______

If yes, where were you treated and when? ______

***

How many caffeinated beverages do you drink a day?(include energy drinks, pop, coffee, tea) ______

Tobacco History

Have you ever smoked cigarettes? ( ) Yes ( ) No Currently? ( ) Yes ( ) NoHow many packs per day on average? ______How many years?______. How many years did you smoke? ______When did you quit? ______

Pipe, cigars, or chewing tobacco: Currently? ( ) Yes ( ) No.In the past? ( ) Yes ( ) No What kind? ______How often per day on average? ______How many years? ______

Social History

How would you describe your childhood? ______

Where did you grow up? Were you adopted? ( ) Yes ( ) No

______

When your mother was pregnant with you, were there any complications during the pregnancy or at birth? Were there any problems with your development that you are aware of?

______

List the name and ages of your brothers and sisters, specify if step or 1/2 siblings.

______

Where your parents married ( ) Yes ( ) No

Did your parents’ ever divorce? ( ) Yes ( ) No If so, how old were you when they divorced ______

If your parents divorced, who did you live with primarily?______

______

How old were you when you left home? ______

Legal:Have you ever been arrested? ______Do you have any pending legal problems? ( ) Yes ( ) No

If yes, please explain ______

Do you have access to firearms? ( ) Yes ( ) No ______

Trauma History:

Did you experience neglect, physical, emotional or sexual abuse as a child?______

Educational History:

Did you have any academic problems? ? ( ) Yes ( ) No If yes, please describe.

Were you ever diagnosed with Attention Deficit Disorder? ( )Yes ( )

______

Did you attend college? ______Where? ______

Major?______What is your highest educational level or degree attained?______

Occupational History:

Are you currently: ( ) Employed ( ) Unemployed ( ) Disabled ( ) Retired

What is/was your occupation? ______

Where do you work? ______For how long? ______

Have you ever served in the military? ______

If so, what branch and when? ______

Honorable discharge ( ) Yes ( ) No Other type discharge ______

Relationship History

Are you currently: ( ) Married ( ) Partnered ( ) Divorced ( ) Single ( ) Separated ( ) Widowed

How long? _____

If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? ______

Are you sexually active? Yes ( ) No ( )

Describe your relationship with your spouse or significant other: ______

Have you had any prior marriages? ? ( ) Yes ( ) No.If so, how many? ______How long did previous marriages last? ______

Do you have children? ? ( ) Yes ( ) No. If yes, list ages and gender ______

______

List everyone who currently lives with you. ______

Family Psychiatric History

Has anyone in your family been diagnosed with or treated for any mental/substance abuse disorders, (or that you have suspected of any of these problems)? If yes, please specify who and any details you may know.

Bipolar disorder______

Schizophrenia ______

Post-traumatic stress______

Attention Deficit Disorder ______

Alcohol abuse ______

Substance Abuse ______

Violence ______

Developmental problems ______

Autism______

Depression ______

Anxiety ______

Anger ______

Suicide ______

Your Medical History

Name of your primary care provider

______

Address and phone number

______

Name of your specialty care provider(s) if any

______

Address and phone number

______

Where and when was your last physical? ______

When was your last lab or any other medical tests (such as an EKG) ? Please provide any details you know.

______

Allergies: (include all allergies)

______

Adverse Drug Reactions:

Drug(s) ______

Response______

Medical hospitalizations

When?______

For what reason?______

Any surgeries?______

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
 / Visual Changes/Loss /  / Shortness of breath /  / Changes in muscle strength
 / Head Injury /  / Asthma or Emphysema /  / Falling
 / Headaches /  / High blood pressure /  / Hepatitis A, B or C
 / Seizures /  / Chest pain, heart attack /  / Sexually Transmitted Infections
 / Hearing Loss /  / Constipation or Diarrhea /  / Elevated cholesterol or glucose levels
 / Nose /  / Difficulty controlling bowel or bladder /  / Diabetes
 / Throat /  / GYN problems /  / Memory problems
 / Thyroid disorder /  / Cancer/Tumors/Cysts /  / Difficulty with sleep
 / Allergies /  / Back Pain /  / Childhood Illness - specify
 / Recent Weight Changes /  / Other pain: /  / Other chronic health issues:

Comments:

______

How would you describe your overall health?

______

What do you do to keep yourself healthy? ______

Current Medication

Name / Dose / Directions / Do you take daily / Do you take as needed only

What over the counter or herbal supplements do you take?

______

If female and in childbearing years, are you currently pregnant, breast feeding or planning a pregnancy soon? _____What is your method of birth control? ______

It is important to be aware that psychiatric medication can affect fetal development.

Current Ht _____ Current Weight _____ Any changes in the last 6 months? Yes/No

Recent Blood pressure (if known)______