Medication management
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Patient Intake Form
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Client Name:
*
Date of Birth:
*
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Height:
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Weight:
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Street Address
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City
*
State
*
Zip
*
Phone Number:
Email:
*
Emergency Contact:
*
Relationship to Emergency Contact:
Primary Care Physician:
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Insurance Provider:
Insurance ID# :
Reason for Visit: Please describe the reason for your visit today and any symptoms or concerns you have been experiencing:
Medical History: Please list any medical conditions you have been diagnosed with:
Hypertension (High Blood Pressure)
Diabetes (Type 1 or Type 2)
Asthma or Chronic Respiratory Conditions
Heart Disease (e.g., Coronary Artery Disease)
Mental Health Conditions (e.g., Anxiety, Depression)
Please list any medications you are currently taking, including dosage and frequency:
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Medication 1:
Medication 2:
Medication 3:
Medication 4:
Pharmacy of choice:
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Name:
Address:
Phone number:
Please list any allergies you have, including medications, foods, and environmental allergies:
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Allergy 1:
Allergy 2:
Allergy 3:
Psychiatric History: Have you ever been diagnosed with a mental health condition before? If so, please specify: (circle or bold answer)
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Anxiety:
Select
YES
NO
Depression:
Select
YES
NO
PTSD:
Select
YES
NO
Eating disorder:
Select
YES
NO
Sleep disorder:
Select
YES
NO
ADHD:
Select
YES
NO
Bipolar:
Select
YES
NO
Schizophrenia:
Select
YES
NO
Other
Have you ever been hospitalized for a psychiatric condition? If yes, please provide details:
Family History: Please provide any information you have about your family history of mental health conditions:
Select Please
Depression
Anxiety
Bipolar disorder
Schizophrenia
Other (please specify) :
Social History:
Living situation:
Employment status:
Support system:
Substance use history: Do you currently use any drugs or alcohol? If yes, please provide details (include substance of choice, duration of use, and last date of use)
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include substance of choice
duration of use
last date of use
Consent for Treatment: I understand that the information provided on this form will be used to determine my treatment plan and that I have the right to review and update this information at any time.
Patient Signature:
Clear Signature
Date:
Thank you for completing this intake form. We look forward to working with you to address your mental health and medication management needs.
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