Patient Intake Form
Name
First Name
Last Name
Birth Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Female
Male
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Insurance Provider
Insurance Card (Front)
Insurance Card (End)
Check all symptoms that apply
Sad/depressed mood
Loss of interest/pleasure
Feeling worthless/guilt
Withdrawn/Social Isolation
Irritability/outbursts of anger
Weight gain/loss
Appetite increase/decrease
Sleep disturbance
Crying spells
Difficulty concentrating
Inflated self-esteem
Grandiosity
Talkative
Flight of ideas
Distractibility
Unrestrained buying sprees
Sexual indiscretions
Excessive pleasure activities
Muscle tension
Heart palpitations
Sweating not due to heat
Trembling/shaking
Shortness of breath
Feeling of choking
Chest pain/discomfort
Feeling dizzy/lightheaded
Compulsions
Fear of losing control
Recurrent/persistent thoughts
Recurrent/intrusive memories
Laxative/diuretic abuse
Trouble following directions
Touchy/easily annoyed
Thoughts of Suicide
Homicidal Ideation
Poor impulse control
Relationship difficulties
Deliberate property destruction
Other
List any chronic health problems you may have
List out all current medication
List out allergies
Have you received any outpatient treatment for a psychiatric condition ?
Yes
No
Have you been hospitalized?
Yes
No
Please select the option that apply regarding your smoking habits
None
0 -1 package a day
1 - 2 packages a day
2+ packages a day
Average # alcoholic drinks per week?
Average hour of sleep per week?
Average # of workouts per week?
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: