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 |
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Substance use history:
Substance |
Dates used |
Date last used |
How much and how often |
Rehab (how long) |
Alcohol |
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Y/N |
Nicotine/Tobacco |
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Y/N |
Marijuana |
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Y/N |
Other |
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Y/N |
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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: ____________________________________________________________________________
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Allergies (including reactions): _____________________________________________________________________________________
What psychiatric medications have you tried in the PAST?
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CURRENT medications with dosages:
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Family psychiatric history:
Who |
Diagnosis |
Suicide |
Current Medications |
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Attempt/Completion |
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Attempt/Completion |
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Attempt/Completion |
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Attempt/Completion |
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Family history of medical problems (include strokes, heart attacks, diabetes, thyroid problems): _________________________________
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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:
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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