CAROLINA PARTNERS IN MENTAL HEALTHCARE, PLLC
4 Doctors Park Ste. 4H
Asheville, NC 28801
Phone (828) 285-9911
♦ New Patient Information ♦
Fax (828) 285-9970
Name:
Date of Birth:
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/
Date:
Reason for Visit: _____________________________________________________________________________________
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♦ Review of Symptoms ♦
Depressed mood
Anxiety
Loss of interest
Fatigue
Irritability
Others not listed:
Please review the following symptoms and circle those items that are a problem for you
Racing thoughts
Excessive worry
Excessive guilt
Unable to enjoy activities
Panic attacks
Changes in sleep
Impulsivity
Increase risky behavior
Increased libido
Hallucinations
Excessive energy
Decreased need for sleep
Suspiciousness
Changes in appetite
Decreased libido
Decreased concentration
Avoidance
Crying spells
Forgetfulness
Phobias/unexplained fears
Have you ever had feelings or thoughts that you didn’t want to live?
Do you currently feel that you don’t want to live?
Have you ever tried to harm or kill yourself before?
♦ Review of Systems ♦
Please review the following symptoms and circle those items that are a problem for you
GENERAL
Unexpected weight loss
CARDIOVASCULAR
Chest pain
GENITO-URINARY
Frequent urine infections
PSYCHOLOGICAL
Feeling depressed
Chronic fatigue
Anemia
Lack of regular exercise
Overweight
Dizzy spells
Fainting spells
High blood pressure
Swollen ankles
Irregular pulse
Shortness of breath
Blood in urine
Kidney stones
Painful urination
Loss of control of urine
Decrease in urine flow
Urination more than 2 times/night
Any venereal disease in past?
Nervous or anxious feeling
Excessive moodiness
Difficulty concentrating
Phobias/unexplained fears
No pleasure in life anymore
EYES
Failing vision
Eye pain
Double vision
Blurred vision
Frequent eye infections
Glaucoma
Cataracts
EAR, NOSE, THROAT
Decreased hearing
Ringing in ear
Frequent ear infections
Frequent nose bleeds
Sinus trouble
Frequent sore throat
Prolonged hoarseness
Tooth or jaw pain
PULMONARY
Pneumonia/pleurisy
Bronchitis/chronic cough
Asthma/wheezing
GASTROINTESTINAL
Recent loss of appetite
Difficulty swallowing
Heartburn/gastritis
Nausea/vomiting
Gall bladder trouble
Jaundice (yellow skin)
Change in stool
Diarrhea
Constipation
Bloody or very black stools
Hemorrhoids
hernia
MUSCULOSKELETAL
Pain in joints
Pain in muscles
Recurrent back pains
Past injury to bones, spine, or joints
Gout attacks in the past
Concerned about osteoporosis
NEUROLOGICAL
Frequent headaches
Tremor/hands shaking
Muscle weakness
Numbness/tingling
Seizures/convulsions
Difficulty sleeping
Excessive daytime sleeping
Memory loss
ENDOCRINE
Excessive thirst and urination
Feet and hands numbness/pain
Low blood sugar problems
Intolerance to heat or cold
HEMTOLOGIC/LYMPHATIC
Excessive bruising or bleeding
Swollen glands- neck, armpit, groin
Fever, chills, night sweats
ALLERGIC/IMMUNOLOGIC
Hey fever/allergies
Getting lots of infections
Desire HIV discussion
Women Only
Periods Irregular
Excessive flow/pain
Hot flashes/ night sweats
Abnormal PAP smear
♦ Medication or Food Allergies or Intolerances ♦
List below medications or foods causing an allergic reaction (i.e., rash, swelling) or intolerance (i.e., nausea)
Medication / Food
Reaction
Medication / Food
Reaction
♦ Current Medications, Vitamins and Herbal Supplements ♦
Medication
Strength
Example: Tylenol
500 mg
Number of pills
taken & frequency
1 - twice daily
Medication
Strength
Number of pills taken
& frequency
♦ Past Psychiatric Medications ♦
Medication Name
Dose
Approx.
Dates Used
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Welbutrin (bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Reaction
Medication Name
Dose
Approx.
Dates Used
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Other:
Other:
Other:
Other:
♦ Past Psychiatric History ♦
Outpatient Treatment:
Yes
Reason
Psychiatric Hospitalization:
Reason
No
Yes
Dates Treated
By Whom
Dates Treated
By Whom
No
Reaction
♦ Past Medical History ♦
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Condition / Disease
Hypertension
High Cholesterol
Hypothyroidism (low thyroid)
COPD, Emphysema or Asthma
Diabetes
GERD
Depression or Anxiety
Heart Problems -
Year Began
Condition / Disease
Year Began
Other(s):
♦ Past Surgical Procedures / Hospitalizations / Serious Injuries or Fractures ♦
Operation / Hospitalization / Injury
Month / Yr
Operation / Hospitalization / Injury
Month / Yr
♦ Disease Prevention and Health Maintenance ♦
Flu Vaccine
Pneumonia Vaccine
Tetanus Vaccine
Hepatitis B Vaccine
Shingles Vaccine
Gardasil Vaccine
Please list below the most recent dates of your vaccines and health screening tests
Month/Yr
Month/Yr
Mammogram
Eye Exam
Pap Smear
Heart Catheterization
Colonoscopy
Endoscopy (EGD)
Bone Density
Heart Stress Test
EKG
Ab Aneurysm Screen
Chest X-Ray
HIV Test
♦ Social, Educational, and Work History ♦
Marital Status:  Single  In Relationship  Partner  Married  Divorced  Widowed
High Education Level:  High school  GED  Some College  College Grad.  Advanced Degree
Are you currently:
 Working  Unemployed  Student  Retired
 Disabled:  Long-term  Short-term  Permanent
Occupation and Employer:
♦ Other Health Related Information ♦
Do you exercise regularly:  Yes  No
What kind of exercise do you do?
If yes, many days per week?
How much time per day?
Have you ever been treated for alcohol or drug use/abuse?  Yes  No
If yes, which substances?
If you, when and where were you treated?
Have you ever smoked cigarettes?  Yes  No
If yes, how long ago did you quit?
Do you currently smoke cigarettes?  Yes  No
If yes, approx. how many per day?
Please specify if you use any other forms of tobacco (e.g. smokeless, pipe, vapor, etc.):
How would you rate your diet?
Please specify if you follow a special diet (e.g. Gluten-free, lactose-free, vegan, etc.):
Caffeine Intake, # drinks per day:
Alcoholic Beverage, # drinks per week:
of  Soda  Coffee  Tea  Energy Drinks  Other:
of  Beer  Wine  Liquor
Month/Yr
♦ Family Psychiatric History ♦
Has anyone in your family been diagnosed with or treated for: (Please indicated who)
Bipolar disorder:
Schizophrenia:
Depression:
Post-Traumatic Stress:
Anxiety:
Alcohol Abuse:
Anger:
Other Substance Abuse:
Suicide:
Violence:
Has anyone in your family been treated with psychiatric medication? If yes, who was treated with what medications and how
effective was the treatment?
♦ Family Health History ♦
Relative
Please list below the health history of your blood (genetic) first degree relatives
Living or
Current age or
Cause of
Health Problems
Deceased
age at death
Death
Father:
Mother:
Brother(s):
Sister(s):
♦ Other Physicians and Specialists ♦
List below your other physicians (i.e., Gyn., Dermatology, GI, Orthopedics, Urology, Psychiatry, etc.)
Primary Care Physician:
Current Therapist/Counselor:  Yes  No
If yes, who and where:
Preferred Pharmacy (Name, Address, Phone):
Other (name and specialty):
Other (name and specialty):
Other (name and specialty):
♦ Anything Else You Want Us To Know ♦
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Signature of Patient, Parent, or Guardian
Date
Signature of Provider
Date