New Patient Form-Adult (Age 18 and over)

New patient form for Adults ages 18 and over

We are not contracted with Medicaid, HIP, or Medicare.

This paperwork is not accepted! Please fill out paperwork that was sent to your e-mail address or contact Intake at

Midwest Behavioral Health. 812- 401-8008 ext. 638

I understand that I am only to complete this paperwork IF I have a scheduled appointment. *

Yes- I do have a scheduled appointment.

Today's Date: * +

Date of Birth: * +

Age: *

Patient First Name: *

Middle initial: *

Last Name: *

Patients Street Address: *

City: *

State: *

Zip: *

Best number to reach you: *

Best time to reach you? *

How did you learn of our office/referred by? *

Current concerns/complaints that have brought you to our office? *

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What led you to seek help now?

Psychiatric/ Behavioral Health History:

Do you have a previous diagnosis? *

YES

NO

When and by whom? *

Please list the names of any psychiatrists, psychologists, or therapists seen in the past (if not local, please list city and state): *

Have there been any related hospitalizations/In-patient of Intensive Outpatient? Please specify dates and locations: *

Other areas of concern (Check all that apply): *

Medical History:

How would you rate your overall health? *

Primary Care Physician: *

Date of last visit: *

Any recent laboratory studies, or blood test, etc.? *

Do you currently have health issues related to Any of the following? (Please check all that appy) *

History of Head injury: *

YES

NO

Loss of Consciousness: *

YES

NO

History of Seizures: *

YES

NO

List any medical hospitalizations and briefly note the reason why:

Please list any surgeries with dates and locations:

Any medication allergies? *

YES

NO

If yes, what are they?

Please list ALL prescription and non-prescription products you take; include nutritional supplements as well: *

Please check any of the medications below that you have been on in the past. *

Other Other

Please bring a list of medications covered by your insurance to your appointment.
I understand that if I fail to provide a copy of the approved medications from my insurance, the doctor may choose a medication that is not covered by my insurance plan. Midwest Behavioral Health will not be responsible for obtaining prior authorization for your medication. *

I have read and understand the above statement.

Do you use tobacco products of any type? *

YES

NO

If yes, how often and how much?

Do you drink alcohol? *

YES

NO

If yes, how often and how much?

Have you ever used marijuana, cocaine, benzodiazepines (Xanax, Klonopin, etc.), pain medication, stimulants (Adderall, Ritalin) that were NOT prescribed specifically for you? *

YES

NO

What is your present marital status? *

Married

Separated

Divorced

Other Other

Who else lives with you? *

If applicable-list your children with their ages:

What is your level of education? *

Are you currently employed? *

YES

NO

If yes, where and for how long?

List any family members (especially parents and siblings) with psychiatric/behavioral health problems and their diagnoses: *

What are your hobbies, interests, &/or leisure activities? *

Please list any past or current legal issues: *

Have you ever served in the U.S. Military? *

YES

NO

If yes, what branch?

Have you ever been emotionally/verbally, physically, or sexually abused? *

YES

NO

If yes, please sepecify age, length of abuse, relationship to abuser, and legal outcome.

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Current Stressors:

Financial

Family

Work

Other Other

Any areas NOT covered that you feel are important to bring to our attention?

What are your treatment goals? *

Mood Disorder Questionnaire (MDQ)

Instructions: Mark the answer that best applies to you. Please answer each question as best you can.

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 in trouble? *

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

...thoughts raced through your head or you couldn't slow your mind down? *

YES

NO

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

YES

NO

...you had much more energy than usual? *

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

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

YES

NO

...spending money got you or your family in trouble? *

YES

NO

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

YES

NO

How much of a problem did any of these cause you-like being able to work; having family, money or legal troubles; getting into arguments or fights? *

No Problem

Minor Problem

Moderate Problem

Serious Problem

Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *

YES

NO

Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *

YES

NO

Patient Health Questionnaire (PHQ-9)
Nine Symptom Depression Checklist

Over the last 2 weeks, how often hav eyou been bothered by any of the following problems?

1.) Little interest or pleasure in doing things *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

2.) Feeling down, depressed, or hopeless *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

3.) Trouble falling or staying asleep, or sleeping too much *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

4.) Feeling tired or having little energy *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

5.) Poor appetite or overeating *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

6.) Feeling bad about yourself-or that you are a failure or have let yourself or your family down *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

7.) Trouble concentrating on things, such as reading the newspaper or watching television *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

8.) Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Thoughts that you would be better off dead or of hurting yourself in some way *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

Adult Self-Report Scale (ASRS) Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria. Answer each question with the answer that best describes how you have felt and conducted yourself over the past 6 months.

*

	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you make careless mistakes when you have to work on a boring or difficult project?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you have difficulty getting things in order when you have to do a take that requires organization?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you misplace or have difficulty finding things at home or at work?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often are you distracted by activity or noise around you?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)
How often do you have problems remembering appointments or obligations?	Often (3)	Sometimes (2)	Very Often (4)	Never (0)	Rarely (1)

*

	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you feel restless or fidgety?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you have difficulty unwinding and relaxing when you have time to yourself?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you feel overly active and compelled to do things, like you were driven by a motor?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you find yourself talking too much when you are in social situations?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you have difficulty waiting your turn in situations when turn taking is required?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)
How often do you interrupt others when they are busy?	Never (0)	Rarely (1)	Sometimes (2)	Often (3)	Very Often (4)

Depression	School Issues	Job Issues	Sleep Disturbances	Substance Abuse
Anxiety/Stress	Hyperactive	Eating Disorder	Suicidal Thoughts	Parent/Child Issues
Sexual Trauma	Attention Problems	Homicidal Thoughts	Physical Abuse	Emotional Abuse
Moodiness	Aggression	Relationship Issues	Legal Issues	Threatens Others

Hypertension	Diabetes	Reflux Disease	Low Blood Pressure	Cancer
High Cholesterol/Triglycerides	Dizziness	Kidney Stones	Thyroid Problems	Chronic Fatigue
Sleep Problems	Heart Disease	Other Other

Ritalin	Vyvanse	Adderall	Concerta	Daytrana
Focalin	Strattera	Intuniv	Viibryd	Pristiq
Cymbalta	Lexapro	Prozac	Zoloft	Paxil
Effexor	Wellbutrin	Lamictal	Depakote	Abilify
Seroquel	Saphris	Risperdal	Geodon	Latuda
Zyprea	Xanax	Ativan	Klonopin	Have not tried any of these medications