Patient Intake - Zen Psychiatric Services

Name

First

Last

Date of Birth

SECTION 1: TREATMENT

How can we help? Please describe as best you can any issues you have been having and what you expect to accomplish with treatment.

What problems are troubling you the most right now?

What are your goals for this treatment?

SECTION 2: CURRENT PSYCHIATRIC & MEDICAL CARE

What person or practice currently prescribes your psychiatric medications?

Mark none if you are currently not being prescribed psychiatric medications.

Do you have another provider or practice prescribing NON-psychiatric medications?

Yes
No

If yes, who is this prescriber?

Who is your preferred pharmacy?

Are you currently receiving counseling or therapy?

Yes
No

If yes, where and how often?

SECTION 3: MEDICAL HISTORY

This section is CRITICAL. Please be thorough and complete with your answers. We want to ensure the best possible outcome for your treatment. Your comfort and safety are vital to this treatment program.

To your knowledge, do you have any aneurysms in any blood vessels?

Yes
No

If so, please explain as best you can

Have you ever had any kind of stroke?

Yes
No

If so, please explain as best you can

Have you ever had an EKG?

Yes
No

If so, when?

Was the EKG normal, abnormal, or unknown?

Normal
Abnormal
Unknown

WOMEN:

When was the date of your last menstrual period?

Are you currently pregnant or think you might be pregnant?

Are you planning to get pregnant in the near future?

Allergies & Medication Side-Effects

Please Note: By allergies, we mean things that you absolutely cannot take because they endanger your life. (example: if Drug X gave you the shakes after taking for several weeks, that’s a side-effect. If Drug X gave you a rash all over or caused you to become so lightheaded you fell, that’s an allergy!) You may add multiple entries by clicking the + symbol.

Drug

What kind of allergic reaction?

Drug Side-Effects

Drug

What kind of side-effect?

SECTION 4: BASIC MEDICAL HISTORY

Personal & Family Medical History

Please check all that apply for you and your immediate family. For any boxes checked, please provide a brief explanation of specific diagnoses or issues.

Did your mother have any complications before or during your birth? If so, please tell us what you know.

Have you ever been hospitalized for MEDICAL or SURGICAL reasons? Please explain:

Please include any dates and at which hospital you were treated.

Please list ALL current medications. (Psych and Non-Psych)

You may add more than one entry by clicking the + symbol.

Medication & Dosage (mg)

How Often Per Day?

Date Started

Please list ANY current over-the-counter medications or supplements.

You may add more than one entry by clicking the + symbol.

Supplement or OTC Medication & Dosage (mg)

How Often Per Day?

Date Started

SECTION 5: SOCIAL HISTORY

What is the highest education level you completed in school?

Are you currently:

If married or in a relationship, for how long?

Are you satisfied with your current relationship?

Are you suffering any type of abuse in this relationship?

Do you have any children or grandchildren? If so, how many?

Have you ever been abused sexually, physically, emotionally, or by neglect? Please explain:

Do any issues regarding your sexual orientation or gender identity distress you? Please explain:

Do you belong to any religion or spiritual group?

Yes
No

If so, does your religion or spiritual group provide emotional support?

Yes
No

Do any issues regarding your religious or spiritual beliefs distress you?

Yes
No

Who are your personal emotional supports (with whom are you close)?

Are you currently:

If disabled, what is your current legal disability?

If working or retired, what is/was your occupation?

Have you ever served in the military?

Yes
No

If yes, what branch and time frame?

Is your current living situation stable?

Yes
No

If no, please give a brief general description of the issues you face.

Does anyone in your home own firearms?

Yes
No

Are those weapons licensed and secured in accordance with local laws?

Yes
No

Do you have any current or pending legal problems?

Yes
No

If yes, please give a brief general description of the issues you face.

Section 6: Substance Use History

In your entire life, have you ever had a problematic pattern of substance use?

Yes
No

Specifically, a pattern that caused you any social, academic, occupational, or legal problems.

If yes, please tell us what substance(s) you struggled with and what problems they caused you.

Have you ever been treated or hospitalized for a substance use disorder?

Yes
No

If yes, please list where and when you were treated.

Are you in any ongoing recovery program?

Yes
No

If yes, please describe which program.

Are you currently struggling with problematic substance use?

Yes
No

If yes, please tell us what substance(s) you are struggling with and the problems they are causing for you.

Are you currently recreationally using any illegal substances or any legally available and/or prescribed substances?

Yes
No

This includes alcohol, marijuana, Delta-8, CBD and kratom.

If yes, please tell us which substance(s) you are currently using, how often, and by what means.

Have you ever tried, even just once in your life, any of the following:

Alcohol History: How many days a week do you drink alcohol?

What is the least number of drinks you will have in one day?

What is the maximum number of drinks you will have in one day?

IN THE PAST 3 MONTHS:

Have you thought you should cut down on your drinking or drug use?

Yes
No

Have people annoyed you by criticizing your drinking or drug use?

Yes
No

Have you felt bad or guilty about your drinking or drug use?

Yes
No

Have you had a drink or a drug first thing in the morning to steady your nerves or fight a hangover?

Yes
No

TOBACCO HISTORY:

Have you ever smoked cigarettes?

Yes
No

Do you currently still smoke cigarettes?

Yes
No

If yes, how many packs per day do you smoke?

If you smoked in the past and quit, how many years did you smoke?

Do you currently use chewing tobacco, dip, smoke a tobacco pipe or cigars?

Yes
No

If yes, please describe which product, how often per day, and how many years you have been using.

SECTION 7: PSYCHIATRIC HISTORY

Outpatient Treatment History:

Have ever had any outpatient psychiatric treatment?

Yes
No

Please list any history of outpatient psychiatric treatment.

You may add more than one entry by clicking the + symbol.

Date Treated

Provider or Practice Name

Problems Treated

Inpatient Treatment History:

Have you ever had any inpatient psychiatric treatment?

Yes
No

Please list any history of inpatient psychiatric treatment.

You may add more than one entry by clicking the + symbol.

Date Treated

Hospital or Treatment Facility

Problems Treated

Suicide Risk Assesment:

Have you ever tried to commit suicide?

Yes
No

Do you currently feel that you don't want to live?

Yes
No

Psychiatric Medication History

Please indicate which of these medications you have taken. In the comments box, please tell us what you can about; how long you took it, the max dose you took, if it helped, didn’t help, or if it possibly hurt you.

Antidepressants:

Frequency Treated dip,

Mood Stabilizers:

Antipsychotics:

Seroquel

Seroquel

Zyprexa

Zyprexa

Geodon

Geodon

Abilify

Abilify

Clozaril

Clozaril

Haldol

Haldol

Prolixin

Prolixin

Risperdal

Risperdal

Anti-Anxiety:

Xanax

Xanax

Ativan

Ativan

Klonipin

Klonipin

Valium

Valium

Tranxene

Tranxene

Buspar

Buspar

Vistaril

Vistaril

Stimulants:

Adderall

Adderall

Concerta

Concerta

Ritalin

Ritalin

Strattera

Strattera

Vyvanse

Vyvanse

Family Psychiatric History:

Has anyone in your family – blood kin, as far and wide as you know – ever tried to hurt or kill themselves?

Yes
No

If yes, please tell us who:

Is anyone in your family – again, blood kin – diagnosed, treated, or struggling with a mental illness?

Yes
No

If yes, please tell us who:

Is there anything else that needed more space to explain? Anything else you want us to know before your evaluation?