MENTAL HEALTH PATIENT INTAKE FORM
Disclaimer: Thank you for your interest in being a patient of MAO Medical Clinic.
form is used to collect information about new clients and for internal purposes only.
The information you provide is confidential and will be treated accordingly.

. ThisPERSONAL INFO
Name: ______________________ Date: ______________ Date of Birth: _______________
Current Physicia:/Clinic/Hospital: __________________
Phone: _________________REASONS FOR VISIT
What are the problems for which you are seeking help?

Current Symptoms: (check all that apply)☐ Racing thoughts☐ Depressed mood
☐ Impulsivity☐ Sleep pattern
disturbance☐ Avoidance☐ Excessive worry☐ Forgetfulness☐ Unable to enjoy
activities☐ Fatigue☐ Suspiciousness☐ Loss of interest☐ Change in appetite☐ Anxiety attacks☐ Excessive guilt☐ Increased risky behavior☐ Increased irritability☐ Increased libido☐ Hallucinations☐ Excessive energy☐ Decreased libido☐ Decreased need for sleep☐ Crying spell☐ ________________________________________

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SUICIDE RISK ASSESSMENT
Have you ever had feelings or thoughts that you didn’t want to live? ☐ Yes ☐ NoIf yes, please answer the following. If no, please skip to the next section.
-Do you currently feel that you don’t want to live? ☐ Yes ☐ No
-How often do you have these thoughts? _________________________________________-When was the last time you had thoughts of dying? ________________________________-Has anything happened recently to make you feel this way? ☐ Yes ☐ No
-On a scale of 1 to 10, how strongly do you feel these thoughts? ______-Would anything make it better? ☐ Yes ☐ No
-Have you ever thought about how you would kill yourself? ☐ Yes ☐ No
-Is the method you would use readily available? ☐ Yes ☐ No
-Have you planned a time for this? ☐ Yes ☐ No
-Is there anything that would stop you from killing yourself? ☐ Yes ☐ No
-Do you feel hopeless and/or worthless? ☐ Yes ☐ No
-Have you tried to kill or harm yourself before? ☐ Yes ☐ No-Do you have access to firearms? If yes, please explain below. ☐ Yes ☐ No____________________________________________________________________________
PAST MEDICAL HISTORY
Do you have any allergies? If yes, specify them: ____________________________________
Current Weight: _________ Current Height: _________
List any prescription medication that you are currently taking and how often you aretaking them:Medication
Total Daily Dosage_____________________________ ___________________________________________ ___________________________________________ ___________________________________________ ______________

Estimated Start Date________________________________________________________

Current over-the-counter medication or supplements: ______________________________
Current medical problems: _____________________________________________________
Past medical problems, nonpsychiatric hospitalization, or surgeries:____________________________________________________________________________Have you ever had an EKG? ☐ Yes ☐ No
If yes, when? ______________

How was the EKG? ☐ Normal ☐ Abnormal ☐ Unknown
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For women only
Date of last menstrual period: ______________ Birth control method: ________________Are you currently pregnant or do you think you might be pregnant? ☐ Yes ☐ No
Are you planning to get pregnant in the near future? ☐ Yes ☐ No
How many times have you been pregnant? _______How many live births? ________

Any concerns about your physical health that you would like to discuss? ☐ Yes ☐ No
If yes, please specify:

Date of last physical exam: _________ Location: __________________________________PERSONAL AND FAMILY MEDICAL HISTORY
Check any that apply to you or a member of your family (specify who if selected):Thyroid disease
AnemiaLiver disease
Chronic fatigue
Kidney disease
Diabetes
Asthma/respiratory problems
Stomach or intestinal problems
CancerFibromyalgia
Heart disease
Epilepsy or seizures
Chronic pain
High cholesterol
High blood pressure
Head trauma
Liver problems
Other: _____________________☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)☐ You ☐ Family member (_______________)

Any other additional personal or family medical history?

When your mother was pregnant with you, were there any complications during thepregnancy or birth? ☐ Yes ☐ No
If yes, please specify:Page 3 of 8

PSYCHIATRIC HISTORY
Outpatient Treatment? ☐ Yes (if yes, specify the details below) ☐ No
Reason_______________________________________________________________________________________

Date Treated__________________________________________

By Whom_________________________________________________________

Psychiatric Hospitalization? ☐ Yes (if yes, specify the details below) ☐ No
ReasonDate Hospitalizednini_____________________________ ___________________________________________ ___________________________________________ ______________

Where_________________________________________________________

List any psychiatric medication you have taken, the dates, dosage, and any side effects:Medication
DateDosage
Side Effects____________________________ _________ _________ _______________________________________________________ _________ _________ _______________________________________________________ _________ _________ _______________________________________________________ _________ _________ ___________________________FAMILY PSYCHIATRIC HISTORY
Has anyone in your family been treated for:☐ Bipolar disorder ☐ Depression ☐ Anxiety ☐ Anger ☐ Suicide ☐ Schizophrenia☐ Post-traumatic stress ☐ Alcohol abuse ☐ Violence ☐ Other: ______________________
If any of the options were selected, specify the family member and the corresponding problem:

Has any family member been treated with psychiatric medication? If yes, who wastreated, what medications did they take, and how effective was the treatment?

SUBSTANCE USE
Have you ever been treated for alcohol or drug use? ☐ Yes ☐ No
-If yes, for which substances? ________________________________________-If yes, where were you treated and when? Date: _________ Location: ___________________

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How many days per week do you drink alcohol? ____
What is the least and the most # of drinks you will drink in a day? Least: ____ Most: ____
What is the most alcohol you have consumed in a day in the last 90 days? ____________Have you ever felt you should cut down on your drinking or drug use? ☐ Yes ☐ No
Have people annoyed you by criticizing your drinking or drug use? ☐ Yes ☐ No
Have you ever felt bad or guilty about your drinking or drug use? ☐ Yes ☐ No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves
or to get rid of a hangover? ☐ Yes ☐ No
Do you think you may have a problem with alcohol or drug use? ☐ Yes ☐ No
Have you used any street drugs in the past 3 months? ☐ Yes ☐ No-If yes, which ones? _________________________________________________________Have you ever abused prescription medication? ☐ Yes ☐ No-If yes, which ones and for how long? _____________________________________________Have you ever tried any of the following?
Substance☐ Methamphetamine☐ Cocaine☐ Stimulants (pills)☐ Heroin☐ LSD or Hallucinogens☐ Marijuana☐ Painkillers (not as prescribed)☐ Methadone☐ Tranquilizer/sleeping pills☐ Alcohol☐ Ecstasy☐ Other: _________________

If so, how long and when did you last use?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PERSONAL HABITS

How many caffeinated beverages do you drink a day? Coffee ____ Sodas ____ Tea ____Have you ever smoked cigarettes? ☐ Yes ☐ No-Currently? ☐ Yes ☐ NoIf yes, how many packs per day on average? ____ How many years have you smoked? ______
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-In the past? ☐ Yes ☐ NoIf yes, how many years did you smoke? ________ When did you quit? _____________
Do you exercise regularly? ☐ Yes ☐ No
-How many days a week? _______How much time each day? _______-What kind of exercise do you do? _____________________________PERSONAL DETAILS
Were you adopted? ☐ Yes ☐ No

Where did you grow up? ______________________

List your siblings and their ages:
Name____________________________________________________________________________________________________________

Age_____
_____
_____
_____

What is/was your parent’s occupation? Father: _______________ Mother: ______________
Did your parents divorce? ☐ Yes ☐ No
-If yes, what age were you? _____ Who did you live with? __________________
Describe your father and your relationship with him:

Describe your mother and your relationship with him:

How old were you when you left home? _______
Has anyone in your immediate family died? If yes, specify who and when:____________________________________________________________________________
Do you have a history of being abused emotionally, sexually, physically, or by neglect? Ifyes, describe when, where, and by whom:

Highest education level attained? ___________________________
Employment status: ☐ Working ☐ Student ☐ Unemployed ☐ Disabled ☐ Retired-How long have you been in your present position? _______-If working or retired, what is/was your occupation? _________________-What location do/did you work? ___________________
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Have you ever served in the military? ☐ Yes ☐ No
-If yes, what branch? ___________________ When did you serve? ___________________-Were you honorably discharged? ☐ Yes ☐ No ☐ Other: ____________________________
Marital status: ☐ Married ☐ Partnered ☐ Divorced ☐ Single ☐ Widowed-How long have you been in your present status? ___________________-If not married, are you currently in a relationship? ☐ Yes ☐ No If yes, how long? __________-If you have a partner or spouse, what is their occupation? ___________________-Describe your relationship with your partner or spouse:

Have you had any prior marriages? ☐ Yes ☐ No
-If so, how many? ____ How long were/was the marriage(s)? ___________________________Are you sexually active? ☐ Yes ☐ No What is your sexual orientation? ________________
Do you have any children? ☐ Yes ☐ No
If yes, specify their age and gender:
Age____
____
____
____

Gender____________________________________

Describe your relationship with your children:

List everyone who currently lives with you:

Have you ever been arrested? ☐ Yes ☐ No

Any pending legal problems? ☐ Yes ☐ NoDo you belong to a particular religion or spiritual group? ☐ Yes ☐ NoIf yes, what is the level of your involvement? _____________________________
Do you find your involvement helpful towards your mental health, or does theinvolvement make things more difficult or stressful for you? ☐ Helpful ☐ Stressful
Is there anything else that you would like us to know?

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ACKNOWLEDGMENT
Signature: ______________________ Date: _______________
Print Name: ______________________

Guardian Signature (if required) ____________________ Date: _______________
Print Name: ______________________

Emergency Contact: ______________________ Phone Number: ______________________

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