Personal information

Personal Information
Instructions
Please fill out this form as completely as you can. Print your answers.
Today's Date
Marital Status
First Name
Ethnicity
Last Name
Gender [ ] Male [ ] Female
Date of Birth
Occupation
Address and
Please give your home address. Please indicate by circling the appropriate letter whether I can leave a full message (“M”), callback number only (“C”), or no message at all (“N”). Home Phone
Cell Phone
Work Phone
Emergency
Please tell me the name of someone to contact in case of an emergency. If any information is the same in the table above, you can write "Same".
Relationship
Home Phone
Cell Phone
Work Phone
Insurance
Although I do not participate with any insurance companies, it is often helpful to me to have your insurance information in case you need tests or hospitalization. Primary Plan
Secondary Plan
Subscriber
Subscriber
Referral source
Please tell me who suggested that you see me. Relationship to
Pharmacies
Please provide contact information for pharmacies you plan to use to fill your prescriptions. Pharmacy
Location
Pharmacy
Location
Doctors and Therapists
Instructions
Please provide contact information for all doctors (including psychiatrists and therapists) whom
you see regularly. Please also include past psychiatrists and therapists. Continue on back if
necessary.
Type of doctor
Type of doctor
Type of doctor
Type of doctor
Type of doctor
Type of doctor
Type of doctor
Type of doctor
Type of doctor
Medical History
Please list all major medical problems and treatments. For example: diabetes, diet & problems
medication; breast cancer, lumpectomy & radiation. Please include head injuries. Continue
on back if necessary.
When diagnosed
Treatment(s)
Date(s) of Treatment(s)
Surgeries
Please list any operations you have had, when and why. For example: appendectomy, 1990, appendicitis. (No need to repeat operations listed above.) Continue on back if necessary. Operation
Allergies &
Please list any medications or foods to which you have had a bad reaction (rash, e.g.). Please Bad Reactions
include any problems with anesthesia. Continue on back if necessary. Medication or Food
Reaction
Please list all medications and supplements that you take. Include drugs that are prescribed by a
Medications &
doctor, vitamins and herbal supplements, and over-the-counter drugs you take frequently. Supplements
Medication or Supplement
Frequency
Reason you take it
Substances
Please check whether you use or have ever used any of the following, prescribed or not. Where multiple substances are listed, please circle all that apply. Continue on back if necessary. Substance
Substance
Opioids (heroin, methadone, pain medication) Symptoms &
Please check any of the following problems or tests you have had in the last year. If given a choice (weight loss or gain, e.g.), please circle applicable symptom(s). Where appropriate, please indicate what body part was tested (X-ray: chest, e.g.). [ ] Persistent loss of sensation/numbness [ ] Jaundice (yellow skin or eyes) [ ] MRI of: Psychiatric History
Hospitalizations
Please list any psychiatric hospitalizations you have had. Continue on back if necessary.
Hospital
When admitted/discharged
Reason hospitalized
Past Medications
Please check any of the following medications that you have taken in the past. Please check any of the following problems that you have had in the last month. Symptoms
[ ] Trouble concentrating [ ] Interacting less [ ] Can’t make decisions [ ] Impulsive behavior [ ] Guilt over bad deeds [ ] Don't trust people [ ] Deserve punishment [ ] Thoughts not your own [ ] Can't throw things away [ ] Trouble getting started [ ] Worry about health [ ] Thoughts being blocked [ ] Afraid to get fat [ ] Life not worth living [ ] Messages from TV/radio [ ] Making yourself vomit [ ] Interpersonal trouble [ ] Thoughts of suicide [ ] Alien force moving your [ ] Using exercise or laxatives Family Psychiatric History
Family History
Have any of your blood relatives been diagnosed with a mental illness? Please indicate their relationship to you and check all that apply. Continue on back if necessary. Relationship to you
Diagnosis (check all that apply)
Treatment (check all
that apply if known)

Source: http://www.organicpsych.com/wp-content/uploads/2012/08/PatientInfo.pdf