Patient Demographics and History Information Form
Patient Name
First Name
Last Name
Patient’s sex
Male
Female
Other
Patient’s Date of Birth
-
Month
-
Day
Year
Date
Patient’s Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact number for patient
Format: (000) 000-0000.
Patient Work Number
Format: (000) 000-0000.
Patient’s Email
example@example.com
Employment Status of Patient
Full Time
Part Time
Not Working
Disabled
Retired
Student
Other
Name of Employer
Marital Status of Patient
Single
Married
Divorced
Widowed
Other
Language(s) spoken by patient
English
Spanish
Other
What category best describes your race (one or more may be marked)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
I choose not to answer
Other
Please specify your ethnicity
Hispanic or Latino
Not Hispanic or Latino
Nationality of Patient
U.S. citizen
Other
Emergency Contact Information
Emergency Contact for patient
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How is the emergency contact related to patient?
Other Contact Name
First Name
Last Name
Other Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Contact Phone Number
Format: (000) 000-0000.
How is other contact related to the patient?
Pharmacy Information
What pharmacy do you use locally?
Local Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Local Pharmacy Phone Number
Format: (000) 000-0000.
What is your mail order pharmacy?
Primary Insurance Information
Insurance Company Name (primary)
Subscriber’s Insurance ID number
Group Number
Primary Insurance Effective Date
-
Month
-
Day
Year
Date
Primary Insurance Subscriber’s Name
Primary Insurance Subscriber’s Date of Birth
-
Month
-
Day
Year
Date
Primary Insurance Subscriber’s Sex
Female
Male
Patient’s relationship to subscriber of Primary Insurance
Spouse
Child
Other
Secondary Insurance Information
Secondary Insurance Carrier
Secondary Insurance Subscriber ID number
Secondary Insurance Subscriber’s Name
First Name
Last Name
Secondary Insurance Subscriber’s Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance Subscriber’s Sex
Female
Male
Patient’s relationship to subscriber of Secondary Insurance
Spouse
Child
Other
Any other information you feel we need to know?
Patient Medical History
Have you ever been treated any of the following medical conditions?
Acid Reflux (GERD)
Arthritis
Asthma
Bleeding Disorders
Cancer
Chronic pain
COPD/Emphysema
Dementia or memory loss
Diabetes mellitus
Head trauma/loss of consciousness
Heart disease/heart attack
Hepatitis B
Hepatitis C
High blood pressure
High choleterol
High thyroid function
HIV disease
Iron deficiency/anemia
Irritable Bowel Syndrome
Kidney disease
Low thyroid function
Migraines or chronic headaches
Parkinson's disease
Pituitary tumor
Seizures/epilepsy
Sleep apnea
Stroke or TIA (min-stroke)
Vitamin B12 deficiency
Vitamin D deficiency
None
Other
Please list any other medical conditions not listed above
Medication Allergies/Adverse Reactions
Surgical History
Current Medications
Primary Care Provider Name
First Name
Last Name
Suffix
Primary Care Provider Phone Number
Format: (000) 000-0000.
Your other healthcare providers
Psychiatric History
Previous mental health provider
Therapist/Counselor Name
First Name
Last Name
Therapist/Counselor Phone Number
Format: (000) 000-0000.
Psychiatric Hospitalizations/Rehab/IOP or PHP
Please list any information on past suicide attempts
Please list information on any history of self harm or mutilation
Please provide any additional information you think your provider should know about your psychiatric history. Thank you.
Family History
Parents' History
Siblings' History
Children's History
Other relatives with relevant psychiatric history
Patient Developmental History
Please list any complications with your pregnancy/birth/delivery
Please list any developmental delays and treatments for them that you underwent as a child (OT, PT, speech therapy, etc)
Please list any learning issues and treatments received as a child (include speech therapy, OT, IEP/540, etc)
Did you have any issues making friends or connecting to people when you were young?
Personal History
Where were you born and raised?
With whom did you grow up
Both parents
Mother
Father
Other relative
Adopted
Other
Highest level of eduation
Non-HS graduate
GED
High School
2 year degree
4 year degree
Graduate degree
Post graduate
Vocational training
Marital Status
Single, never married
Divorced and single
Divorced and remarried
Widowed and single
Widowed and remarried
Separated
Partnered
Married
Other
Partner's name
Years together
With whom do you live?
Employment
Full Time
Part time
Stay at home
Retired
Unemployed/not working
Furloughed
Short term disability
Long term disability
Student
Self employed
Other
Occupation
Employer
First Name
Last Name
What branch(es)?
Air Force
Army
Coast Guard
Marines
National Guard
Navy
Other
How long did you serve?
Legal History
None
Arrest
DUI
Jail/Prison time
Currently on probation
Other
Please list hobbies and interests/community organizations that you enjoy.
Regular Exercise
None
Cardio
Weight training
Other
Pets at home
Have you ever been the victim of violence?
Emotional
Domestic violence
Physical
Sexual
Witnessed abuse/violence
None
Other
Substance Use History
How many servings of caffeine do you consume in an average day?
Please Select
0
1-2
3-4
5-6
>6
Recreational Drug use
Rows
Past Use
Current Use
Rehab
Canabis/THC
1
2
None
1-2 Times
>3 times
Cocaine/crack
3
4
None
1-2 Times
>3 times
Meth
5
6
None
1-2 Times
>3 times
Stimulants
7
8
None
1-2 Times
>3 times
Ketamine
9
10
None
1-2 Times
>3 times
MDMA (Ecstasy)
11
12
None
1-2 Times
>3 times
Psilocybin (shrooms)
13
14
None
1-2 Times
>3 times
LSD
15
16
None
1-2 Times
>3 times
Huffing
17
18
None
1-2 Times
>3 times
Pain pills/Heroin
19
20
None
1-2 Times
>3 times
Alcohol Use
Please Select
Never
A few times a year
A few times a month
A few times a week
Daily
Alcohol Quantity
Please Select
1-2 servings
3-4 servings
5-6 servings
7-8 servings
9-10 servings
>10 servings
Have you ever experienced any of the following due to alcohol use?
Blackouts
Withdrawal seizure
Other severe withdrawal symptoms (high BP, high HR, agitation, confusion)
Delirium tremendous (DTs)-requires hospitalization
Mild withdrawal symptoms (nausea, shakes, sweating)
Memory loss
Needing an “eye opener”-drinking upon wakening
Craving alcohol when not drinking
Have you required the following treatment due to alcohol use?
Medical hospitalization for detox
Non-ICU Detoxification
>90 day residential treatment
30-60 day residential treatment
Long term sober living
Intensive outpatient rehab program
Alcoholic Anonymous or other recovery program
Any other information regarding substance use that you feel your provider needs to know?
Is there anything else you feel your provider needs to know? Any specific issues you hope to address at your first appointment?
Submit
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