Dr. Diez, Clinical Psychologist, Columbus Circle, New York City

 

 

INTAKE FORM

Name _________________________________________________     Gender _______ Date of Birth ________

Street address: ____________________________________________________________________________

City ________________________________ State _______________ZIP ______________________________

Home phone (         ) -___________________ Alt. phone (            )-_____________________________________

Referred by _______________________________________________________________________________

Person to contact in an emergency __________________________ Phone (___)-________________________

Address ____________________________________________ Relationship to you _____________________

Persons with whom you live and their relationship to you:

_______________________________________________________________________________________


_______________________________________________________________________________________

Children:   NO _____    YES____ (Please answer bellow)

Name                                                                                            Age
________________________________________________     _______________

________________________________________________     _______________

________________________________________________     _______________

Occupation or work emphasis _______________________________________ Years of Education _______

Education major or training emphasis________________________________________________________

Employer_________________________________________________ Years worked there _____________

Marital status (i.e. single, married, separated, divorced, living with partner) _________

Spouse/partner name ____________________________ Spouse/partner occupation __________________

Outpatient Medical Record - Please check all those that have occurred at any time.
Head injury___ Learning Problems ___ Alcoholism___ Substance Abuse___Hepatitis___ Chicken Pox___ Rheumatic Fever__Thyroid Problems__ Whooping Cough__ Hernia___Cancer/Tumor___ Poliomyelitis___ Sinus Problems____ Food Tolerance___Speech Problems__ Epilepsy___ Bronchitis___ Measles___ Scarlet Fever___Typhoid Fever___ Hearing Problems___ Asthma___Mumps___Bulimia/Anorexia___ Tuberculoses___ Special Diets___ STD___ Appendicitis___ Hypertension___ Stroke___ Anemia___ Kidney Disease___ Diabetes___ Smallpox___ Tonsillitis___ Pregnancies___Heart Palpitations___ Pneumonia___ Neurological disease________Other __________________________________________
Gastrointestinal problems: __________________________Significant weight loss/gain ____________________________
Allergies (food, drug, other: please list)_________________________ HIV Positive? Yes ____ No ____ How Long? _________


Do you experience any of the following? Abdominal Pain_______ Changes in Appetite_______ Dizziness_______Bed Wetting_________ Headaches______________ Fatigue_________Frequent Urination_____ Fainting Spells___________ Chest Pain______ BreathingProblems_______Nausea_________Colds_______________Nosebleeds____Constipation_____Sore throat___________ Coughs________________ Toothache_______ Menstrual Problems____     Diarrhea_____________ Vomiting_______________ Ear Infection_____ Eye Vision Problems___ Memory Problems ____

 List any of the operations, Medical Procedures or Hospitalizations for medical, psychiatric/emotional, drug or alcohol problems. Please include Dates.
_______________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Legal Status i.e. Are you currently involved with the criminal justice system? _____________________________________


Do you use any of the following?

How long used?

How much used?

Alcohol

___________________

___________________

Tobacco

___________________

___________________

Nonprescription Drugs

___________________

___________________



Prescription drugs taken currently or in the past 6 months
:


Prescription drug name

Frequency/Dosage

Reason Prescribed

___________________

___________________

____________________________

___________________

___________________

____________________________

___________________

___________________

____________________________

___________________

___________________

____________________________


Note any of the side effects of adverse reactions to medications listed above:

_______________________________________________________________________________________

Please help me understand what problems brought you to this office. Check all that apply: Marital___ Job___ Career_____ School___ Alcohol___ Substance Abuse___ Depression___ Moodiness__ Self Confidence___ illness___ Fatigue___ Psychological___ Children___ Family___ Sexual Problems___ Traumatic Experience___ Loneliness___

Other or elaborate on above ________________________________________________________________


Are you currently having any suicidal ideation?_________________________________________________

Previous Counseling or Psychotherapy? (please indicate when, where, with whom and whether it was as a child, adult, couple or court ordered)

________________________________________________________________________________________

Previous contact with psychiatrist for medication, or psychologist for psychological evaluation: NO _____ YES_____

(Reason, date, lenght of Tx)___________________________________________________________________


_____________________________________________________________________________________
Patient’s signature                                                                                 Date                                            Name (printed)
 
Last updated on May 2014 | New York City