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Patient Intake - Brave Health
Patient Intake Questionnaire
Required Fields (
*
)
Contact Name
*
Date of Birth MM/DD/YYYY
*
Email
*
Phone
*
Reason for Visit
*
Current psychiatric medications and doses
Preferred Pharmacy (type none if not applicable)
*
Preferred Lab
Please check all that apply
Depressed mood
Hopeless or helpless
Little or no interest in activities
Feelings of guilt
Feelings of worthlessness
Low self-esteem
Decreased Energy
Decreased Concentration
Changes in appetite or weight
Moving slower or speaking slowly
Feeling fidgety or have feeling of inner restlessness
Increased or decreased libido
Fatigued / tired most days
Feel irritable often for no reason
Harder to make decisions than it used to be
Sleep problems
Hard to get to sleep, but I stay asleep
Hard to stay asleep
Hard to get to sleep and hard to stay asleep
Ideas of suicide or death
Panic attacks
Fear of social situations
Compulsions
Mood swings or irritability
Anger outbursts
Decreased need for sleep
More talkative
Racing thoughts
At times, I become overly distractible where even small things pull me away from important things
At times, I do more risky things that often turn out badly
At times, I am more impulsive than usual and do things that are out of character for me
At times, I start many projects or get into so many activities that I can’t complete and I jump from one to another rapidly
At times, I am unusually irresponsible and take action that causes moderate to severe problems (legal, financial, relationship) for me and my family
I have experienced a traumatic event
I often have the same nightmare or bad dream
Memories come into my mind when I don’t want them
Sometimes I feel numb all over when I have some memories
I avoid certain people and places I go
Sometimes I feel so much fear
I am hyper-vigilant / hyper-aware even when no danger is present
I have many body aches and pains
I have neck, back and other chronic pain
I have headaches / migraines often
I have had a head injury in the past
I feel threatened or scared
I feel people are out to get me
I can read other peoples thoughts
Other people can read my mind and/or thoughts
The TV or radio talks to me
I hear voices others cannot
I see things that others cannot
I have intrusive thoughts that are not my own
I have special abilities or powers others do not have
Thoughts are put inside my head by others
I sometimes have out of body experiences
Psychiatric History
Past Psychiatrist
Date Last Seen
Past Psychiatric Diagnosis
Past Psychiatric Medications
Have you ever been hospitalized for any psychiatric reasons?
–None–
Yes
No
If yes, how many times?
What was the reason?
What was the date(s)?
Where were you hospitalized?
Have you ever attempted to commit suicide?
–None–
Yes
No
If yes, how did you attempt to kill yourself?
How many times did you attempt suicide?
What was the date(s)?
Medical History
Current Medical Issues
Current Non-psychiatric Medications
Allergies
Surgical History
Past Surgeries (Include date/hospital/physician)
Family Psychiatric History (please check all that apply & list family member(s))
Depression
Depression – family member(s)
Anxiety
Anxiety – family member(s)
Bi-polar
Bi-polar – family member(s)
Schizophrenia
Schizophrenia – family member(s)
Suicidal Attempts
Suicidal Attempts-family member(s)
ADD / ADHD
ADD / ADHD – family member(s)
Alcoholism
Alcoholism – family member(s)
Drug abuse
Drug abuse – family member(s)
Dementia
Dementia – family members(s)
Social History
Smoking status
–None–
Current Smoker
Former Smoker
Non-Smoker
Vaping
Chewing tobacco
If a current smoker, how many cigarettes per day?
Alcohol consumption
–None–
Non-Drinker
Occasional
Social
Rare
Daily
Drinks per day?
I usually drink
–None–
Beer
Wine
Liquor
Do you have a history of substance or alcohol abuse?
–None–
Yes
No
If so, please explain
Have you ever been treated for substance abuse?
–None–
Yes
No
If so, where were you treated?
Marital Status
–None–
Single
Married
Divorced
Widowed
How long
Children
Employment Status
–None–
Employed
Unemployed
Disability
Retired
Employer
If, on disability, please explain why
Education Level
–None–
High School
College Level
College Graduate
Postdoctoral
Currently residing with
–None–
I am living alone
I am living with a family member
I am living with a spouse or significant other
Other
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
–None–
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless?
–None–
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much?
–None–
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy?
–None–
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating?
–None–
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself-or that you are a failure or have let yourself or your family down?
–None–
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television?
–None–
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed?
–None–
Not at all
Several days
More than half the days
Nearly every day
Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual?
–None–
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way?
–None–
Not at all
Several days
More than half the days
Nearly every day
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