Medical History Form - Adults - Gerardo P. Sison Jr., MD - Psychiatry

Phone

Medical History Form for Adults

First Name

Middle Name

Last Name

Address

City

State

ZIP

Contact Number

Email Address

Sex

Male

Female

Marital Status

Employer

Work Phone

In case of emergency:

Emergency Contact Name

Relationship

Contact Number

Who referred you to this office?

Name of Insurance Company

Group Number

You are required to obtain the first authorization number from your insurance company:

Name of Policy Holder

Date of Birth

Relationship to Patient

Social Security Number

CO-PAYMENTS AND/OR DEDUCTIBLES ARE DUE AT TIME OF EACH VISIT

Medical History

Do you have any current medical problems? (please describe)

Is it being treated?

Yes

If yes, by whom?

Who is your primary care physician?

If you want your referring physician notified of assessment information and treatment recommendations, you must complete the authorization for the Release of Confidential Information.

What medication(s) are you taking?

Please list any drug allergies.

Alcohol Consumption

Do you sometimes drink more than you have planned?

Yes

Have family or friends ever expressed concern about your drinking?

Yes

Have you ever been treated for drinking? (gone to AA)

Yes

Indicate which of the following you use (have used)

Tranquilizers (Valium, Librium, Xanax, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Pain Pills (Codeine, Percodan, Demerol, Dilaudid, Heroin, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Diet Pills (Amphetamines, Speed, Dexedrine, Ritalin, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Sleeping Pills (Phenobarbital, Doriden, Placidyl, Dalmane, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Hallucinogens (Marijuana, Hashish, THC, LSD, Psilocybin, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Cocaine (Crack, Base, Snow, Blow, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Volatiles (Aerosols, Paint Thinner, Glue, etc.)

Use currently (within 1 year)

Have used in the past

Have never used

Have family or friends ever expressed concern over your use of drugs?

Yes

Have you ever been arrested for any offense involving drugs?

Yes

Have you ever been treated for substance abuse?

Yes

Have you ever overdosed on drugs (accidental or purposeful)?

Yes

Medical History Continued...

Zung Self-Rating Depression Scale

Please complete the following. Read each sentence carefully. For each statement, check the bubble in the column that best corresponds to how often you have felt that way during the past two weeks.

For statements 5 and 7, if you are on a diet, answer as if you were not.

1. I feel downhearted, blue, and sad.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

2. Morning is when I feel the best.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

3. I have crying spells or feel like it.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

4. I have trouble sleeping through the night.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

5. I eat as much as I used to.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

6. I enjoy looking at, talking to, and being with attractive women/men.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

7. I notice that I am losing weight.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

8. I have trouble with constipation.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

9. My heart beats faster than usual.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

10. I get tired for no reason.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

11. My mind is as clear as it used to be.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

12. I find it easy to do the things I used to do.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

13. I am restless and can't keep still.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

14. I feel hopeful about the future.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

15. I am more irritable than usual.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

16. I find it easy to make decisions.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

17. I feel that I am useful and needed.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

18. My life is pretty full.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

19. I feel that others would be better off if I were dead.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

20. I still enjoy the things I used to do.

None or a little of the time

Some of the time

Good part of the time

Most or all of the time

Medical History Continued...

The Mood Disorder Questionnaire

Please answer each question as best as you can.

1. Has there ever been a period of time when you were not your usual self and...

... you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

Yes

... you were so irritable that you shouted at people or started ﬁghts or arguments?

Yes

... you felt much more self-conﬁdent than usual?

Yes

... you got much less sleep than usual and found you didn't really miss it?

Yes

... you were much more talkative or spoke much faster than usual?

Yes

... thoughts raced through your head or you couldn‘t slow your mind down?

Yes

... you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes

... you had much more energy than usual?

Yes

... you were much more active or did many more things than usual?

Yes

... you were much more social or outgoing than usual. for example. you telephoned friends in the middle of the night?

Yes

... you were much more interested in sex than usual?

Yes

... you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

Yes

... spending money got you or your family into trouble?

Yes

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

Yes

3. How much of a problem did any of these cause you - like being unable to work; having family, money, or legal troubles; getting into arguments or ﬁghts? Please select one response only.

No problem

Minor problem

Moderate problem

Serious problem