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Grassroot Psychiatry Mental Health Clinic
Take care of your health and happiness with us
Primary Menu
Home
About
Team
Services
Anxieties
Depression
Panic Attacks
ADHD
Psychosis
PTSD
Addictions
Substance Abuse
Bipolar Disorders
Mood Disorders
Schizophrenia
ODD & DSDM
Policies
Forms
Contact
Psychiatric Intake Assessment Form
Patient Name
*
Email Address
*
Date of Birth
*
Time in
*
Accompanied by
*
Emergency number
*
Relationship to the patient
*
Patient Alternate phone number
*
ALLERGIES:
None known
*
Explain
CURRENT MEDICATIONS:
Name
*
Dosage/Frequency
*
When started
CHIEF COMPLAINT/DURATION: (per triage sheet)
MEDICAL HISTORY:
B/P
*
P
*
Ht
*
Wt
*
Primary care physician
*
Recent labs
EEG
CT/MRI
Constitutional (eg: weight loss, fever)
Yes
No
GI/Liver
Yes
No
Musculoskeletal
Yes
No
Cancer
Yes
No
HEENT
Yes
No
Skin
Yes
No
Allergic/Immunologic
Yes
No
Hospitalizations
Yes
No
Cardiovascular/Hypertension
Yes
No
Neurological (eg: Seizure, CVA)
Yes
No
Hematologic/Lymphatic
Yes
No
Respiratory (eg: COPD, asthma)
Yes
No
GU
Yes
No
Endocrine (eg: diabetes, thyroid)
Yes
No
Head/trauma
Yes
No
Surgeries
Yes
No
Significant Dx’s
Yes
No
BIOLOGICAL FAMILY MEDICAL HISTORY:
Cardiovascular/Hypertension
Yes
No
Neurological (eg: seizures, CVA, Parkinsons, Huntingtons)
Yes
No
Respiratory (eg: COPD, asthma)
Yes
No
Endocrine
Yes
No
Alcohol/Substance abuse
Yes
No
GI/Liver
Yes
No
Cancer
Yes
No
GU
Yes
No
Other
Yes
No
Psychiatric history
Yes
No
SOCIAL HISTORY:
Born where?
*
Raised where?
*
Birth order
*
Brothers
Sisters
Parents divorced?
Yes
No
Specifics
Members in household *
*
Marital status and/or current relationship
S
M
D
W
How long?
When?
Comments:
Children
Yes
No
How many sons?
*
Daughters?
*
Education
Problems
Job description
How long?
Problems?
Military history
PAST PSYCHIATRIC HX:
History of emotional, physical or sexual abuse:
Current Stressors: legal, financial, interpersonal:
Current Stressors: legal, financial, interpersonal:
VEGETATIVE SYMPTOMS:
Sleep
Yes
No
Energy
Yes
No
Concentration
Yes
No
Hopelessness
Yes
No
Appetite
Yes
No
Interest/Motivation
Yes
No
Memory
Yes
No
Manic Symptoms
Yes
No
ANXIETY SYMPTOMS:
OCD Symptoms
Yes
No
Current
Yes
No
Homicidal or Assaultive Behaviors:
Yes
No
Cognitive Deficits: (MR, intellectual decline, wandering)
Yes
No
Comments:
Yes
No
(panic, phobias, autonomic symptoms, generalized anxiety)
Yes
No
(Auditory/Visual Hallucinations, paranoia, delusional ideas)
Yes
No
Past
Yes
No
Eating Disorder:
Yes
No
ADD Symptoms:
Yes
No
Intake RN Signature
Date
*
SUBMIT
Email
Call
Patient
Appointment
