PSYCHIATRY – NEW ADULT PATIENT FORM PG 1 OF

2 KONFERENCJA NAUKOWOSZKOLENIOWA NT OPINIODAWSTWO SĄDOWOPSYCHIATRYCZNE W SPRAWACH TESTAMENTOWYCH
24TH EUROPEAN CONGRESS OF PSYCHIATRY MADRID 2016 EPA COURSE
AMERICAN ACADEMY OF PSYCHIATRY AND THE LAW CALL FOR

ASSOCIATION OF DIRECTORS OF FORENSIC PSYCHIATRY FELLOWSHIP ONE REGENCY
ATTITUDES TO PSYCHIATRY IN MALAWI MEDICAL STUDENTS FOLLOWING AN
BADANIA STOSOWANE W PSYCHIATRII WYWIAD PSYCHIATRYCZNY INFORMACJE NT

Endocrine – New Patient Form

Psychiatry – New Adult Patient Form Pg 1 of 2



Patient’s name: ________________________________________ Date: ___________________

Age: ______ Gender: _______ Date of Birth: _________________

Primary Care Physician’s name: _____________________________


Reason for visit: _________________________________________________________________________________________________


How long have you had these symptoms? _____________ Severity level (circle one): Mild/Moderate/Severe


Have you seen a psychiatrist before? Y/N Have you seen a therapist before? Y/N

If yes, what diagnosis have you been given? __________________________________________________________________________


How many psychiatric hospitalizations have you had? ___________________________________________________________________

Dates

Hospital

Reason











Substance use history:

Substance

Dates used

Date last used

How much and how often

Rehab (how long)

Alcohol




Y/N

Nicotine/Tobacco




Y/N

Marijuana




Y/N

Other




Y/N





Y/N


Medical history:

High blood pressure: Y/N Thyroid Problems: Y/N Hepatitis: Y/N

Diabetes: Y/N Seizure Disorder: Y/N Head injury: Y/N

Heart attack: Y/N High cholesterol: Y/N


Any other medical problems or surgeries: ____________________________________________________________________________

______________________________________________________________________________________________________________


Allergies (including reactions): _____________________________________________________________________________________


What psychiatric medications have you tried in the PAST?

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________


CURRENT medications with dosages:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________


Family psychiatric history:

Who

Diagnosis

Suicide

Current Medications



Attempt/Completion




Attempt/Completion




Attempt/Completion




Attempt/Completion



Family history of medical problems (include strokes, heart attacks, diabetes, thyroid problems): _________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________




Psychiatry – New Adult Patient Form Pg 2 of 2


Social history:

Are you (circle one) Married/Single/Separated/Divorced?

Who currently lives with you? ______________________________________________________________________________

How many children do you have and how old are they? __________________________________________________________

Do you (circle one) rent or own where you live?

Who is your best social support? _________________________________________________________________________


How far did you get in school? _____________________________________________________________________________________

Do you currently work? Y/N

What is your occupation and how long have you done it? _______________________________________________________________


Have you been arrested or placed in jail before? Y/N

How many times, how long and what for? _____________________________________________________________________


Have you ever been abused: physically? Y/N sexually? Y/N emotionally? Y/N

Did you know the person who did the abuse? Y/N


Please place a check if you have recently had any of these symptoms:


( ) Depressed mood ( ) Racing thoughts ( ) Excessive worry

( ) Unable to enjoy activities ( ) Impulsivity ( ) Panic attacks

( ) Poor sleep ( ) Increase in risky behaviors ( ) Avoidance behaviors

( ) Decreased interest ( ) Increased libido ( ) Nightmares

( ) Poor concentration ( ) Decreased need for sleep ( ) Flashbacks

( ) Forgetfulness ( ) Excessive energy ( ) Obsessions/Compulsions

( ) Change in appetite ( ) Irritability ( ) Binge eating

( ) Excessive guilt ( ) Crying spells ( ) Restrictive eating

( ) Feelings of worthlessness ( ) Hallucinations ( ) Excessive working out

( ) Low energy ( ) Paranoia ( ) Fever

( ) Decreased libido ( ) Suicidal thoughts ( ) Unintentional weight gain/loss

( ) Vision changes ( ) Hearing loss ( ) Headaches/Migraines

( ) Chest pain ( ) Abnormal heart rate ( ) Shortness of breath/Difficulty breathing

( ) Nausea/Vomiting ( ) Diarrhea/Constipation ( ) Painful or bloody urination

( ) Rash or skin lesions ( ) Tingling or numbness ( ) Joint pain or muscle weakness

( ) Excessive urination ( ) Heat/cold intolerance ( ) Confusion


Other symptom/problems:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________



Patient’s name _______________________________________________________________ Date ______________________________


BIOLOGICAL PSYCHIATRY MANUSCRIPT SUBMISSION FORM THIS FORM SHOULD BE
CASE REPORT IN PSYCHIATRY GENERAL INFORMATIONS A) THE CASE
CHILD AND ADOLESCENT PSYCHIATRY IN ICELAND REPORT FROM A


Tags: adult patient, new adult, adult, patient, psychiatry