Adult Intake About Yourself Family Family Medical History Psychiatric History Url 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 (please include street address and ZIP code) * 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 * Are you currently involved in any legal difficulties? Yes No If yes, please explain briefly Have you had any legal problems in the past? Yes No If yes, please explain briefly Do you identify with any specific religious, spiritual or cultural affiliation? Yes No If yes, please explain briefly b. Do you participate in any religious, spiritual or cultural practices? Yes No If yes, please explain briefly Emergency Contact Full Name * Relationship with you * Spouse Partner Mother Father Guardian Parent Brother Sister Sibling Friend Son Daughter Child Prefer not to answer Contact Phone Number * Emergency Contact Address * Spouse/Partner's Full Name Spouse/Partner's Date of Birth Describe your relationship with your spouse/partner Spouse/Partner's Occupation Spouse/Partner's Employer Relationship Status (check all that apply) Married Living together Separated Divorced Never lived together Remarried Amicable Conflictual Other 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 disorder, 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 Seizure(s) Childhood Currently Current Care Team (please provide name(s) below) Primary Care Physician Specialist Psychiatrist Therapist Current general medication(s), dosage(s), and purpose(s) n/a Current psychiatric medication(s), dosage(s), and purpose(s) n/a Any other serious medical problems? Any other serious medical problems? Patient Reported Outcome Measurement Information System (PROMIS) Global Health v1.2 - Short Form In general, would you say your health is... 1 excellent. very good. good. fair. poor. In general, would you say your quality of life is... 2 excellent. very good. good. fair. poor. In general, how would you rate your physical health? 3 In general, how would you rate your mental health, including your mood and ability to think? 4 Excellent Very good Good Fair Poor In general, how would you rate your satisfaction with your social activities and relationships? 5 Excellent Very good Good Fair Poor In general, please rate how well you carry out your social activities and roles (activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend). 6 Excellent Very good Good Fair Poor To what extent are you able to carry out your everyday activities such as walking, climbing stairs, carrying groceries, or moving a chair? 7 Excellent Very good Good Fair Poor In the last seven days, how often have you been bothered by emotional problems such as feeling anxious, depressed or irritable? 8 0 1-2 days 3-5 days 6-7 days In the last seven days, how would you rate your fatigue on average? 9 0 - no pain 1 2 3 4 5 6 7 8 9 10 - worst pain imaginable In the last past seven days, how would you rate your pain on average? 10 0 - no pain 1 2 3 4 5 6 7 8 9 10 - worst pain imaginable 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 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? Other symptoms or concerns n/a Are you presently using any other drugs recreationally? Tobacco Marijuana Heroin Tranquilizers Amphetamines Barbiturates Cocaine Opiates Other How much alcohol do you drink per week?
