New patient form for Adults ages 18 and over
We are not contracted with Medicaid, HIP, or Medicare. 
 
 
I understand that I am only to complete this paperwork IF I have a scheduled appointment. If I do not have an appointment I understand that I am to complete the Self-Referral Intake Form first. IF YOU DO NOT HAVE AN APPOINTMENT, PLEASE DO NOT COMPLETE THIS FORM. YOU WILL NEED TO COMPLETE THE SELF-REFERRAL INTAKE FORM. *
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Psychiatric/ Behavioral Health History: 
Do you have a previous diagnosis? *
Other areas of concern (Check all that apply): *

Medical History:
How would you rate your overall health? *
Do you currently have health issues related to Any of the following?  (Please check all that appy) *
 
History of Head injury: *
Loss of Consciousness: *
History of Seizures: *
Any medication allergies? *
Please check any of the medications below that you have been on in the past. *
 
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. *
Do you use tobacco products of any type? *
Do you drink alcohol? *
Have you ever used marijuana, cocaine, benzodiazepines (Xanax, Klonopin, etc.), pain medication, stimulants (Adderall, Ritalin) that were NOT prescribed specifically for you? *
What is your present marital status? *
 
Are you currently employed? *
Have you ever served in the U.S. Military? *
Have you ever been emotionally/verbally, physically, or sexually abused? *
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Current Stressors:
 
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? *
...you were so irritable that you shouted at people or started fights or arguments? *
...you felt much more self-confident than usual? *
...you got much less sleep than usual and found you didn't really miss it? *
...you were much more talkative or spoke faster than usual? *
...thoughts raced through your head or you couldn't slow your mind down? *
...you were so easily distracted by things around you that you had trouble concentrating or staying on track? *
...you had much more energy than usual? *
...you were much more active or did many more things than usual? *
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? *
...you were much more interested in sex than usual? *
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? *
...spending money got you or your family in trouble? *
If you checked YES to more than on of the above, have several of these ever happened during the same period of time? *
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? *
Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? *
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? *
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 *
2.) Feeling down, depressed, or hopeless *
3.) Trouble falling or staying asleep, or sleeping too much *
4.) Feeling tired or having little energy *
5.) Poor appetite or overeating *
6.) Feeling bad about yourself-or that you are a failure or have let yourself or your family down *
7.) Trouble concentrating on things, such as reading the newspaper or watching television *
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 *
Thoughts that you would be better off dead or of hurting yourself in some way *
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. 
 *
 Sometimes (2)Never (0)Often (3)Rarely (1)Very Often (4)
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a take that requires organization?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you have problems remembering appointments or obligations?
 *
 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?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you find yourself talking too much when you are in social situations?
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?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?