INTAKE VITAL INFO
PART II

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First Name * Mid

Last Name *

Email * Cell Number

Street Address City
State Zip-Code *
Country

Physician's Name Physician's Tel # Date Last Dr Visit

Chief Complaint - Reason for Contact

Prior Psychiatric Contacts

Yes No

Prior Psychiatric Medications

Yes No

Are you Presently on Psych Meds

Yes No

Prior Psychotherapy

Yes No

Prior Family Therapy

Yes No

Prior Group Therapy

Yes No

Prior AA

Yes No

Prior NA, GA

Yes No

Prior ACOA

Yes No

Prior ALANON

Yes No

Prior Rehab or Residential

Yes No

Have you or your partner, had a child recently ?

Yes No

Are you or your partner, pregnant now ?

Yes No

Have you recently experienced a devastating loss

Yes No

Have you recently had a traumatic experience

Yes No

Ever wished to be dead.

Yes No

Ever had thoughts of harming yourself

Yes No

Have you ever attempted suicide

Yes No

Have you ever harmed or cut yourself

Yes No

General Medical Info

Gastro-Intestinal

Abdominal Pain Syndrome.
Acid Reflux, Heartburn, GERD.
Belching, Bloating, Flatulence.
Biliary Tract Disorders.
Chron's
Dyspepsia/Indigestion.
Gallbladder Disorders.
Gallstone Pancreatitis.
Nausea and Vomiting.
Peptic Ulcer Disease.
None Reported

Cardio-Vasc-Pulmonary

Apnoea
Arterior-sclerosis
Asthma
Bronchitis
Congestive heart
COPD
Emphysima
Hypertension
Oncological
None Reported

Endocrinological

Adrenal insufficiency
Cushing’s
Hepatitis
Hypopituitarism
Hypothyroidism
Multiple endocrine neoplasia
Polycystic ovary (PCOS)
Precocious puberty
None Reported

Genito-Urinarary

Bladder
Cystitis
Ed
Endometriosis
Frequency of Urination
Hydrocele
Incontinence
Kidney stone -disorders
Nephrotic syndrome
Prostatic Hypertrophy
Renal failure
Uteri disorders
None Reported

AutoImmune

Addisons
Celiac disease
Crohn’s disease
Chronic Fatigue
Graves
Hashimoto’s disease
Hiv
Lupus
Ms
Psoriasis
Sjögren’s syndrome
Vitiligo
None Reported

Orthopedic

Arthritis
Rheumatoid Arthritis
Bursitis
Fibromyalgia
Gout
Kyphosis
Low Back Pain
Musculo-skeletal Pain
Osteoporosis
Paget's Disease
Scoliosis
Spinal Stenosis
None Reported

Episodic Discomfort

Anxiety
Bad dreams
Compulsions
Confusion
Dizzines
Inrtusive thoughts
Mitral-Valve Prolapse
Panic
Paranoia
Phobias
Sweating
Tachycardia
None Reported

Have you ever been on :

Amphetamines- ADD
Analgesics-Pain Relief
Antibiotics
Anticoagulants
Antidepressants
Anxiety Medications
Blood Pressure
Cholesterol - Triglycerides
Diabetes
Lithium
Seizure Medications
Sleep Medications
None Reported
Other - Describe Below

List Current meds ?

Amphetamines ADD
Analgesics-Pain Relief
Antibiotics
Anticoagulants
Antidepressants
Anxiety Medications
Blood Pressure
Cholesterol - Triglycerides
Diabetes
Lithium
Seizure Medications
Sleep Medications
None Reported
Other - Describe Below

Medical-Procedures

Accupancture
Chropractic
Cosmetic
ECT
Lithotripsy
Physical Therapy
Prostate-BPH
Radiation
Reflexology
Spinal
Surgeries Other
TMS
None Reported
Other - Describe Below

Hematologic

Anemia
Hemolytic anemia
Iron deficiency
Sickle cell
Thalassemia
None Reported

Add comments Re: Med Info

Silly Questions

People in Glass Houses should
not Throw Stones because ...

They can be arrested
They will break the glass
The pot should not call the kettle black
It makes no sense

Better a bird in the hand, than 3 in the bush

It makes less noise
The bird will be safer
I love a sure thing
Don't count your eggs before they hatch

Personality Traits and Status

Facial Expression

animated
intense
serious
stone-faced
unemotional
constricted
blunted
restrained
passionate
dramatic

Interests

socializing
romantic
sports
exercising
music-movies
casinos
video-games
arts
travel
politics
adventure

Decisiveness Ambivalence

very decisive
impetuous
impulsive
hesitant
uncertain
indecisive
tentative
tenuous
ambivalent
calculating

Present Status

bitter
hurt
angry
content
depressed
anxious
discouraged
happy
satisfied
unhappy

Organizational

obsessive
organized
disorganized
intermittent
selective
hoarding
list-making
protracting
procrastinating

Dress Style

trendy
swank
ornate
chic
sporty
casual
accessorized
unkempt
frumpy

Energy Level

high
moderate
low
minimal
vascilating
vigorous
episodic
lethargic
tireless

Quality of Speech

soft
slow
fast
direct
elaborate
loud
measured

Interpersonal

affectionate
caring
charming
engaging
huggy-Kissy
loving
thoughtful

Amiability

animated
attentive
considerate
humorous
likable
mindful
social

Sociability

active
cautious
cheerful
courageous
lively
outgoing
playful

Disposition

candid
outspoken
quiet
reserved
sincere
tolerant
uninhibited

Stability

balanced
capricious
Impulsive
Irritable
moody
erratic
stable

Weaknesses

possessive
capricious
Impulsive
Irritable
moody
erratic
stable
arrogant

Add comments Re: Personality Traits and Status

Contact Psych-Skype

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INTAKE VITAL INFOPART II

Chief Complaint - Reason for Contact

General Medical Info

Add comments Re: Med Info

Silly Questions

Personality Traits and Status

Add comments Re: Personality Traits and Status

Notes & Navigation

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Assessments

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INTAKE VITAL INFO
PART II