Microsoft word - program intake packet revised 2010 03 3

Thank you for taking the time to fill out these forms. Please answer the questions to the best of your ability. The information we collect will be helpful to your clinician and provide the cornerstone for future preventative studies. The information gathered here will be kept strictly confidential. NAME: _______________________________________________ DATE: ____/____/____ AGE:________ ADDRESS: ________________________________________________________________________________________ ________________________________________________________________________________________ PHONE NOS. - HOME: _____________________ CELL: _____________________ WORK: ____________________ EMAIL: __________________________________________ SSN: __________________________________________ ٠ DURING THE LAST MONTH, WHAT WAS YOUR LEVEL OF FUNCTION AT WORK? Never married / living with partner ____ (how long) Married ____ (how long) _____ (number of times) Living with your family of origin (parents, etc) Living with your partner / significant other Living as a single parent with your child(ren) Living on your own (alone or with roommate) ٠ YOUR OB/GYN’S NAME / ADDRESS / PHONE __________________________________________________________ __________________________________________________________ __________________________________________________________ ٠ HOW OLD WERE YOU WHEN YOU HAD YOUR FIRST MENSTRUAL PERIOD? ___________________ ٠ HOW MUCH PAIN DO YOU USUALLY HAVE WITH YOUR PERIODS? Mild cramps or infrequent pain, medication seldom needed Moderate cramps, medication usually needed Severe cramps, medication and bed rest needed Regular _____ (average number of days per cycle) ٠ DO YOU OR THE BABY’S FATHER HAVE A HISTORY OF: ٠ HAVE YOUR PERIODS EVER STOPPED TEMPORARILY? If yes, mark which event caused your periods to stop and how long: Hormonal Medication [Lupron (Luprolide), Danocrine (Danzol), Synarel (Nafareline), Depo-provera] ٠ HAVE YOU EVER BEEN TOLD THAT YOU HAD ANY OF THE FOLLOWING CONDITIONS? ٠ WHAT KIND OF BIRTH CONTROL ARE/WERE YOU CURRENTLY USING? ___________ ٠ WHAT BIRTH CONTROL METHODS HAVE YOU USED IN THE PAST AND WHEN? I WILL BE AGE 35 OR OLDER AT THE TIME OF DELIVERY? If any of these tests were positive please describe: __________________________________________ ____________________________________________________________________________________ IS THERE A FAMILY HISTORY OF (Patient, Father of the baby, or a close relative in either family) Thalassemia Other Chromosomal anomalies, birth defects, or inherited genetics disorders not listed above? ______________________________________________________________________________________ ٠ HOW MANY TIMES HAVE YOU BEEN PREGNANT? (including current pregnancy) . . . . . . . . ____ ٠ HOW MAY FULL-TERM DELIVERIES? (≥ 37 completed weeks) . . . . . . . . . . . . . . . . . . . . . . . ____ ٠ HOW MANY PRETERM DELIVERIES? (≥ 20 TO < 37 completed weeks) . . . . . . . . . . . . . . . ____ ٠ HOW MANY MISCARRIAGES? (pregnancy loss before 20 completed weeks) . . . . . . . . . . . . . ____ ٠ HOW MANY ABORTIONS HAVE YOU HAD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ٠ HOW MANY LIVING CHILDREN DO YOU HAVE? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ If one of your children has died, please explain the circumstances: ___________________________ ____________________________________________________________________________ ٠ HOW MANY MULTIPLE GESTATIONS AND BIRTHS HAVE YOU HAD? . . . . . . . . . . . . ____ ٠ DID YOU EVER TRY FOR > 2 YEARS TO GET PREGNANT OR HAVE REPEATED PROBLEMS ٠ HAVE YOU EVER USED FERTILITY MEDICATIONS SUCH AS CLOMID OR PERGANOL or IN VITRO FERTILIZATION? YES NO WHAT WAS THE NAME OF THE MEDICATION? ______________________________________ Please Include: Abortions, Stillborns, Miscarriages and Ectopic Pregnancies Type: i.e. Vaginal, C/S, Forceps or Vacuum Anesthesia: i.e. Epidural, Local, General, Demerol Complications: i.e. Diabetes, Bleeding, Hypertension ٠ WHAT WAS THE FIRST DAY OF YOUR LAST MENTRUAL PERIOD? ٠ WHAT IS YOUR ESTIMATED DATE OF DELIVERY? ٠ WHAT WEEK OF YOUR PREGNANCY DID YOU BEGIN FEELING DOWN? _____________________ OR WHAT WEEK POSTPARTUM DID YOU BEGIN FEELING DOWN? _____________________ ٠ PLEASE LIST ANY MEDICATIONS (OVER THE COUNTER & PRESCRIPTIONS) TAKEN DURING YOUR PREGNANCY. _______________________________________________________________ ٠ WHEN DID YOU START YOU PRENATAL VITAMIN? ________________________________________ ٠ DO YOU HAVE OR HAVE YOU HAD ANY OF TH EFOLLOWING IN YOUR CURRENT PREGNANCY? If you are currently pregnant, please skip this section. ٠ WHAT METHODS HAVE YOU/ARE YOU USING TO FEED YOUR BABY? ٠ PEDIATRICIAN’S NAME AND ADDRESS: ___________________________________________________ ___________________________________________________ ٠ HAS YOUR MENSTRUAL CYCLE RETURNED? YES NO ٠ DID YOU HAVE ANY HELP WITH THE BABY AFTER THE HOSPITAL? NO YES, WHO? _______________________________________ ٠ YOUR CURRENT PSYCHIATRIST OR THERAPIST’S NAME / ADDRESS / PHONE __________________________________________________________ __________________________________________________________ __________________________________________________________ ٠ PREVIOUS SUICIDE ATTEMPTS OR SELF-INJURY? LIST NUMBER OF TIMES, METHODS, DATES: _______________________________________________________________________________________________ ٠ PREVIOUS HOMICIDE OR VIOLENCE (INCLUDING CHILDREN)? _______________________________________________________________________________________________ ٠ PREVIOUS OUTPATIENT PSYCHIATRIC TREATMENT? WHERE AND WHEN? FOR WHAT PERIOD OF TIME? _______________________________________________________________________________________________ ٠ PREVIOUS PSYCHIATRIC HOSPITALIZATIONS? WHERE AND WHEN? FOR WHAT PERIOD OF TIME? _______________________________________________________________________________________________ ٠ HAS A PROFESSIONAL, FRIEND, OR FAMILY MEMBER EVER SAID YOU WERE DEPRESSED OR HAD ANXIETY? NO YES, WHO? __________________________________________________________ ٠ HAVE YOU EVER SOUGHT TREATMENT FOR DEPRESSION OR ANXIETY? YES NO ٠ HAVE YOU EVER HAD PSYCHOTHERAPY AS YOUR MAIN TREATMENT? YES NO ٠ HAVE YOU EVER SOUGHT TREATMENT FOR ANY OTHER PSYCHIATRIC CONDITION? YES NO IF YES, WHAT? ___________________________________________________________ ٠ HAVE YOU EVER BEEN TOLD BY A CLINICIAN THAT YOU HAVE ANY OF THE FOLLOWING: Other, Please Specify __________________________ Attention Deficit Hyperactivity Disorder ٠ WHICH OF THE FOLLOWING PSYCHIATRIC MEDICINES HAVE YOU TAKEN IN THE PAST? Medication Other Mood Stabilizer / AED (Name __________) Ritalin / Concerta / Metadate (methylphenidate) Other Sleep Medication (Name __________) BARBITURATES, BENZODIAZEPINES, QUAALUDES, DOWNER’S HALLUCINOGENS UPPERS, SPEED, CRANK, ICE, 8-BALLS NARCOTICS HEROIN, PERCODAN, DEMORAL, DILAUDID, METHADONE INHALANTS GASOLINE, GLUE, PAINT THINNER, WHITE-OUT, HUFFING ٠ TREATMENT FOR DRUG OR ALCOHOL ABUSE: LIST LOCATIONS, DATES OF TREATMENT, DURATION. INPATIENT DETOX____________________________________________________________________________ LONG-TERM RESIDENTIAL______________________________________________________________________ OUTPATIENT_________________________________________________________________________________ NA/AA MEETINGS_____________________________________________________________________________ ٠ LONGEST PERIOD OF SOBRIETY: _______________________________________________________________ ٠ LEGAL PROBLEMS RELATED TO DRUG/ALCOHOL USE: ٠ WITHDRAWAL SYMPTOMS / MEDICAL PROBLEMS FROM DRUG/ALCOHOL USE: ________________ __________________________________________________________________________________________________ ٠ HAVE ANY OF THE FOLLOWING BEEN DIAGNOSED IN YOUR FAMILY? MAJOR DEPRESSION ٠ CURRENT WEIGHT (lbs) ____________٠ YOUR PRE-PREGNANCY WEIGHT (lbs) _____ ٠ DO YOU HAVE ANY ALLERGIES (medication or other)? Reaction: __________________________________________________________________________ ٠ PAST OR CURRENT MEDICAL PROBLEMS (Please check ALL that apply to you.) ٠ LIST ALL PRESCRIPTION MEDICINES, INCLUDING PSYCHIATRIC, OVER-THE-COUNTER MEDICINES, VITAMINS, & HERBS YOU HAVE TAKEN IN THE LAST MONTH: How many cigarettes per day? _____________ ٠ HOW MANY CUPS OF CAFFEINATED BEVERAGES DO YOU DRINK PER DAY?_______________ ٠ RELIGIOUS AFFILIATION_____________________________ ٠ ARE YOU CURRENTLY HAVING PROBLEMS WITH ANY OF THE FOLLOWING SYMPTOMS? __Sad Mood ٠ ANY OTHER SPECIAL PROBLEMS OR STRESSES CURRENTLY? __________________________________________________________________________________ _________________________________________________________________________________________ Since the majority of our patients have children and very busy schedules, we understand that occasionally it may be necessary to cancel an appointment. We do not bill for cancellations as we typically have a waiting list, but we ask that you call at least 24 hours prior to your appointment to cancel. If you do not cancel an appointment within 24 hours, it is considered a “missed” appointment. It is the policy of the Emory Women’s Mental Health Program to terminate your care after two missed appointments. I have read and understand the cancellation policy of the Emory Women's Mental Health Program. ___________________________________________ ____/____/____ Signature

Source: http://www.womensmentalhealth.emory.edu/New%20Patients/WMHP%20Intake%20-%20Revision%202010.03.31.pdf