Patient Intake Form

Basic Information

Full Name Date of Birth Gender Phone Number Email Street Address City, State, Zip Social Security Number Marital Status Ethnicity Religion Primary Language Emergency Contact Name Emergency Contact Phone Primary Care Physician Insurance Provider

Current Symptoms Checklist

Symptom	Mild	Moderate	Severe
Aggression
Judgment errors

Medical History

Current Medications (Name, Dosage, Estimated Start Date) Describe current physical health List any known allergies Past nonpsychiatric hospitalizations or surgeries Do you exercise regularly?

Personal and Family Medical History

Have you or a family member ever had any of the following? Please specify family member if applicable.

Condition	You	Family	If family, Who?
Alzheimer's/Dementia
Head Injury

Emotional/Psychiatric History

Prior Outpatient Treatment? If yes, please describe (Reason, Dates, Treated By Whom) Prior Inpatient Treatment? If yes, please describe (Reason, Date Hospitalized, Where)

Family History: Has anyone in your family been treated for the following? Check all that apply.

Condition	Father	Mother	Aunt	Uncle	Brother	Sister	Children	Grand-parent
Depression

Past Psychiatric Medications

Please indicate if you have ever taken any of the following medications and provide details.

Medication	Taken (Yes/No)	When?	Dosage	Did it help?	Any side effects?
Prozac (fluoxetine)

Substance Use History

Substance Use Status Treatment History (check all that apply)

Substance	Ever Used?	First Use Age	Last Use Age	Currently Used?	Frequency	Amount
Alcohol
Amphetamines (Speed)

Socio-Economic History

Living Situation:

Adequate Homeless Overcrowded Dependent on others for housing Housing dangerous/deteriorating Living companions dysfunctional

Social Support System:

Supportive network Few friends Substance-use-based friends No friends Distance from family of origin

Financial Situation:

No current financial problems Large indebtedness Poverty or below-poverty income Impulsive spending Relationship conflicts over finances

Employment:

Legal History

No legal problems Now on parole/probation Arrests not substance-related Arrests substance related Court ordered this treatment Jail/prison times

Military History

Consent and Policy Acknowledgment

I consent to treatment and services at Safe Meadow Health Center. I acknowledge that I have been informed of my civil rights. I consent to recommended medication treatment if needed. I acknowledge that I have read and understood the attendance policy. I acknowledge that I understand the grievance procedure.

Safe Meadow Health Center - Patient Intake Form