Adult Intake About Yourself Family Family Medical History Psychiatric History Name First Name * Preferred Name Last Name * Birth Date * Gender Identity * Female Male Transgender FTM Transgender MTF Questioning or other Preferred Pronouns she/hers/her he/his/him they/their/them ze/hir/hir other Email Address * Mobile Phone * Mailing Address * Insurance Company * Wellmark Blue Cross/Blue Shield of Iowa HealthPartners: UnityPoint Other: we are out-of-network, you will be a private pay client. Member ID/Policy Number * Group Number Who referred you to our office? Occupation Employer Education Presenting Concerns/Reason for Service Spouse/Partner's Full Name Date of Birth Relationship Married Living together Separated Divorced Never lived together Remarried Amicable Conflictual Other Occupation Employer Emergency Contact Full Name * Relationship with you * Contact Phone Number * Emergency Contact Address * Child 1 Child 1 Your parents are? Married Living together Separated Divorced Never lived together Remarried Amicable Conflictual Other Mother's Occupation Father's Occupation Describe what growing up in your family was like Did you experience physical, verbal, sexual or emotional abuse as a child or teen? (Please explain) n/a Please list psychiatric or medical conditions of your biological relatives including your siblings, parents, maternal and paternal grandparents. Please note conditions such as depression, anxiety, ADHD, bipolar, substance abuse, or other medical or psychiatric conditions: n/a Sibling 1 Sibling 1 Have you ever had any of the following? Allergies Childhood Currently Heart Problems Childhood Currently Epilepsy or Seizures Childhood Currently High blood pressure Childhood Currently Asthma Childhood Currently Vision Problems Childhood Currently Hearing Problems Childhood Currently Surgery Childhood Currently Serious head injury or Concussion(s) Childhood Currently Headaches or Migraines Childhood Currently Thyroid condition Childhood Currently Diabetes Type 1 Type 2 Primary Care Physician Specialist Psychiatrist Therapist Current general medications and dosages n/a Current psychiatric medications and dosages n/a Any other serious medical problems? Any other serious medical problems? Check all that apply Have you previously been diagnosed with ADHD? Have you ever seen a counselor or psychiatrist before? Have you ever been diagnosed with depression? Have you ever made any suicide attempts? Have you ever had problems with anxiety? Have you ever been treated for alcohol/drug problems? Are you presently using any other drugs recreationally? Marijuana Heroin Tranquilizers Amphetamines Barbiturates Cocaine Opiates Other How much alcohol do you drink per week? Have you ever had any of the following? Prolonged periods of sadness/depression Past Present Excessive anxiety Past Present Panic or anxiety attacks Past Present Compulsive habits or rituals Past Present Eating or appetite concerns Past Present Sleep difficulties or concerns Past Present Manic episodes Past Present Thoughts of suicide Past Present Self-harm Past Present Other symptoms or concerns n/a
