Jieun Kim,MD
215-771-1434
[email protected]
www.DrKimChildPsychiatry.com
ADULT INTAKE FORM
Date: ______________ Name of Patient: _______________________________________
Age: _____ Date of Birth: _____________
Street Address: _____________________________________________________________
City: _____________________________________ State: ______ Zip: _____________
Home Phone: _______________________ Daytime Phone: ________________________
Occupation: ____________________________ Employer: _________________________
Address: ___________________________________________________________________
Referred by ________________________________ Phone: ________________________
Please describe the PROBLEM for which you are seeking help:
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Please describe any MEDICAL PROBLEMS and all current medications:
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Please indicate any PRIOR PSYCHIATRIC TREATMENT and psychiatric MEDICATIONS which
have been prescribed and reactions to them: _______________________________________
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Is there any FAMILY HISTORY of psychiatric problems? If so, please indicate:
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Has there been a period of at least 2 weeks during which MOOD HAS BEEN SAD OR EMPTY
most of the day, nearly every day? Yes___ or No___ Or IRRITABLE? Yes___ or No___
Or markedly DECREASED INTEREST OR PLEASURE in almost all activities? Yes__ or No__
Please underline any of the following symptoms occurring:
Significant weight loss or weight gain or appetite decrease or increase
Insomnia or excessive sleep nearly every day
Feeling slowed down and having trouble moving
Needing to keep moving, being unable to sit still
Fatigue or loss of energy nearly every day
Feelings of worthlessness or inappropriate guilt (not merely self reproach or guilt about being sick)
Trouble concentrating or making decisions
Recurrent thoughts of death or suicide
Low self esteem
Feelings of hopelessness
What do you think is causing your depression? ______________________________________
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Has there been a period of at least 4 days during which MOOD HAS BEEN ELEVATED OR
HIGH? Yes___ or No___ Or IRRITABLE? Yes___ or No___
If yes to either, please underline which of the following were also present:
The feeling of being a very important person or having special powers, plans, or abilities
Sleeping less than usual for 3 days or more and feeling rested after only 3 hours,
or between 3-6 hours of sleep
More talkative than usual or pressure to keep talking
Racing thoughts
Trouble concentrating on what was going on because your attention kept jumping to
unimportant things around you
Excessive planning and excessive participation in, multiple activities, or being physically
restless, or being excessively sexual
Excessive involvement in pleasurable activities that could have gotten you into trouble like
unrestrained buying sprees, sexual indiscretions, or foolish business investments
Number of alcoholic drinks consumed per week: _____
Number of cups of coffee consumed per day: _____ Decaffeinated? Yes___ or No___
Number of cigarettes smoked per day? _____
Do you use street drugs? Yes___ or No___ Which street drugs? ______________________
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How severe is your ANXIETY on a scale of 0-10? _____ Do you have panic attacks that
develop abruptly and reach a peak within 10 minutes? Yes___ or No___
If yes, please underline which symptoms occur during an attack:
Palpitations, pounding or accelerated heart
Sweating
Shaking
Shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, light-headed, or faint
Derealization (feelings of unreality)
Depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness or tingling sensations)
Chills or hot flushes
FEARS OR PHOBIAS. Please underline specific examples or fill in the details
Do you find yourself fearful in situations in which other people are not necessarily afraid, such
as fears of being outside the home alone, in crowds, standing in line, in a car, bus, plane, on a
bridge, or in a tunnel?
Other marked and persistent excessive fear of a specific object or situation:
Animal type: ____________________________________
Natural environment (e.g., heights, storms, water) _________________________________
Blood injection or injury type ____________________________________
Situational type (e.g., airplanes, elevators, enclosed places) _________________________
Other type (e.g., phobic avoidance of situations that may lead to choking, vomiting, or
contracting an illness: _______________________________________________________
Do you have a marked and persistent fear of social or performance situations in the presence of
unfamiliar people or possible scrutiny by others (with fears of acting in a way or showing anxiety
that will be humiliating or embarrassing)? Yes_ or No_?
If so, please underline those that apply.
The social fear is generalized and involves most social situations or interpersonal interactions
The social fears are more specific and involve only performance, such as (please underline
those that apply): speaking, auditioning, performing, writing, eating and drinking in public,
urinating in public, bathrooms, or interactional fears limited to one or two life domains
Other fears or phobias: _________________________________________________________
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Do you have OBSESSIONS (unwanted thoughts, images, or impulses that are persistent and
cause marked anxiety or distress)? Yes___ or No___
Check off any obsessions below:
____ Thoughts about contamination (such as becoming contaminated by shaking hands),
____ Repeated doubts (such as wondering whether one has performed some act such as
having hurt someone in a traffic accident or having left a door unlocked),
____ A need to have things in a particular order (and having intense distress when objects
are disordered or asymmetrical),
____ Aggressive or horrific impulses (such as to hurt one’s child or to shout an obscenity in
church), or unwanted sexual imagery (e.g., a recurrent pornographic image).
Other unwanted obsessions: _____________________________________________________
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Do you have COMPULSIONS (behaviors you must do repeatedly or thoughts you must think
over and over) in order to prevent or reduce anxiety or distress (not to provide pleasure or
gratification)? Yes___ or No___
Check off any compulsions below:
____ Having to count over and over to certain numbers
____ Hand washing
____ Repeating rituals a certain number of times
____ Checking things over and over
____ Ordering or arranging
____ Hoarding or collecting
____ In order to feel reassured, requiring another person to answer the same question over
and over or to repeat certain words such as _______________________________________
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Are there any other issues you’d like to address?
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