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Mental Health Intake Form
Mental Health Intake Form
Patient First Name:
Patient Last Name:
Name of Person completing form (if other than patient):
Date Completed:
Patient Date of Birth:
Primary Care Physician:
Physician Phone:
Current Symptoms Checklist (please check all appropriate columns)
Aggression
Mild
Moderate
Severe
Agitation
Mild
Moderate
Severe
Anger
Mild
Moderate
Severe
Anxiety
Mild
Moderate
Severe
Appetite change
Mild
Moderate
Severe
Change in libido
Mild
Moderate
Severe
Compulsions
Mild
Moderate
Severe
Crying/tearful
Mild
Moderate
Severe
Cyber addiction
Mild
Moderate
Severe
Delusions
Mild
Moderate
Severe
Depression
Mild
Moderate
Severe
Disorientation
Mild
Moderate
Severe
Difficulty getting out of bed
Mild
Moderate
Severe
Difficulty making decisions
Mild
Moderate
Severe
Distractibility
Mild
Moderate
Severe
Eating disorder
Mild
Moderate
Severe
Elevated mood
Mild
Moderate
Severe
Emotional trauma perpetrator
Mild
Moderate
Severe
Emotional trauma victim
Mild
Moderate
Severe
Excessive energy
Mild
Moderate
Severe
Excessive energy
Mild
Moderate
Severe
Fatigue
Mild
Moderate
Severe
Grief
Mild
Moderate
Severe
Guilt
Mild
Moderate
Severe
Gambling
Mild
Moderate
Severe
Hallucinations
Mild
Moderate
Severe
Hearing voices
Mild
Moderate
Severe
Heart palpitations
Mild
Moderate
Severe
Hopelessness
Mild
Moderate
Severe
Hyperactivity
Mild
Moderate
Severe
Impulsivity
Mild
Moderate
Severe
Irritability
Mild
Moderate
Severe
Judgment errors
Mild
Moderate
Severe
Loneliness
Mild
Moderate
Severe
Loss of interest in activities
Mild
Moderate
Severe
Memory impairment
Mild
Moderate
Severe
Mood swings
Mild
Moderate
Severe
Obsessions
Mild
Moderate
Severe
Oppositional behavior
Mild
Moderate
Severe
Panic attacks
Mild
Moderate
Severe
Paranoia
Mild
Moderate
Severe
Phobias/fears
Mild
Moderate
Severe
Physical trauma perpetrator
Mild
Moderate
Severe
Physical trauma victim
Mild
Moderate
Severe
Poor concentration
Mild
Moderate
Severe
Poor grooming
Mild
Moderate
Severe
Racing thoughts
Mild
Moderate
Severe
Recurring thoughts
Mild
Moderate
Severe
Self-mutilation
Mild
Moderate
Severe
Sexual addiction
Mild
Moderate
Severe
Sexual difficulties
Mild
Moderate
Severe
Sexual trauma perpetrator
Mild
Moderate
Severe
Sexual trauma victim
Mild
Moderate
Severe
Sleep problems
Mild
Moderate
Severe
Speech problems
Mild
Moderate
Severe
Social isolation
Mild
Moderate
Severe
Substance abuse
Mild
Moderate
Severe
Suicidal thoughts
Mild
Moderate
Severe
Worried
Mild
Moderate
Severe
Worthlessness
Mild
Moderate
Severe
Other:
Mild
Moderate
Severe
Other:
Mild
Moderate
Severe
Other:
Mild
Moderate
Severe
MEDICAL HISTORY
Current Medications
Medication Name
Medication Name
Medication Name
Medication Name
Medication Name
Total Daily Dosage
Total Daily Dosage
Total Daily Dosage
Total Daily Dosage
Total Daily Dosage
Estimated Start Date
Estimated Start Date
Estimated Start Date
Estimated Start Date
Estimated Start Date
Describe current physical health:
Good
Fair
Poor
List any known allergies:
Past nonpsychiatric hospitalizations or surgeries:
Do you exercise regularly?
Yes
No
Personal and Family Medical History (Have you or a family member ever had any of the following? If family, specify which family member)
Alzheimer’s/Dementia
You
Family
Who
Who
Anemia
You
Family
Who
Who
Arthritis
You
Family
Who
Who
Asthma
You
Family
Who
Who
Behavioral problems
You
Family
Who
Who
Birth defects
You
Family
Who
Who
Cancer
You
Family
Who
Who
Chronic Fatigue
You
Family
Who
Who
Chronic Pain
You
Family
Who
Who
Diabetes
You
Family
Who
Who
Ear/Nose/Throat Problems
You
Family
Who
Who
Eating Disorder
You
Family
Who
Who
Emotional Problems
You
Family
Who
Who
Endocrine/Hormone Problems
You
Family
Who
Who
Epilepsy or Seizures
You
Family
Who
Who
Eye Problems
You
Family
Who
Who
Fibromyalgia
You
Family
Who
Who
Gastrointestinal Problems
You
Family
Who
Who
Genital/Gynecological Problems
You
Family
Who
Who
Head Injury
You
Family
Who
Who
Heart Disease
You
Family
Who
Who
High Blood Pressure
You
Family
Who
Who
High Cholesterol
You
Family
Who
Who
HIV Positive or AIDS
You
Family
Who
Who
Kidney Problems
You
Family
Who
Who
Liver Problems/Hepatitis
You
Family
Who
Who
Lung Disease
You
Family
Who
Who
Mental Retardation
You
Family
Who
Who
Migraine or Cluster Headaches
You
Family
Who
Who
Neurological Problems
You
Family
Who
Who
Skin Disease
You
Family
Who
Who
Sleep Apnea
You
Family
Who
Who
Stroke
You
Family
Who
Who
Thyroid Disease
You
Family
Who
Who
Tuberculosis
You
Option Family
Who
Who
Urological Problems
You
Family
Who
Who
Viral Illness/Herpes
You
Family
Who
Who
Other
You
Family
Who
Who
EMOTIONAL/PSYCHIATRIC HISTORY
Prior Outpatient Treatment?
Yes
No
If yes, please describe:
Reason
Reason
Reason
Dates Treated
Dates Treated
Dates Treated
Where
Where
Where
Prior Inpatient Treatment (for psychiatric, emotional, or substance abuse disorder)?
Yes
No
If yes, please describe:
Reason
Reason
Reason
Date Hospitalized
Date Hospitalized
Date Hospitalized
Where
Where
Where
Family History (has anyone in your family ever been treated for any of the following)?
Depression
Father
Mother
Uncle
Brother
Sister
Children
Aunt
Aunt (Depression)
Maternal
Paternal
Uncle
Uncle (Depression)
Maternal
Paternal
Grandparent
Grandparent (Depression)
Maternal
Paternal
Anxiety
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Anxiety)
Maternal
Paternal
Uncle
Uncle (Anxiety)
Maternal
Paternal
Grandparent
Grandparent (Anxiety)
Maternal
Paternal
Panic Attacks
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Panic Attacks)
Maternal
Paternal
Uncle
Uncle (Panic Attacks)
Maternal
Paternal
Grandparent
Grandparent (Panic Attacks)
Maternal
Paternal
Post Traumatic Stress
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Post Traumatic Stress)
Maternal
Paternal
Uncle
Uncle (Post Traumatic Stress)
Maternal
Paternal
Grandparent
Grandparent (Post Traumatic Stress)
Maternal
Paternal
Bipolar Disorder/Manic Depression
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Bipolar Disorder/Manic Depression)
Maternal
Paternal
Uncle
Uncle (Bipolar Disorder/Manic Depression)
Maternal
Paternal
Grandparent
Grandparent (Bipolar Disorder/Manic Depression)
Maternal
Paternal
Schizophrenia
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Schizophrenia)
Maternal
Paternal
Uncle
Uncle (Schizophrenia)
Maternal
Paternal
Grandparent
Grandparent (Schizophrenia)
Maternal
Paternal
Alcohol Problems
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Alcohol Problems)
Maternal
Paternal
Uncle
Uncle (Alcohol Problems)
Maternal
Paternal
Grandparent
Grandparent (Alcohol Problems)
Maternal
Paternal
Drug Problems
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Drug Problems)
Maternal
Paternal
Uncle
Uncle (Drug Problems)
Maternal
Paternal
Grandparent
Grandparent (Drug Problems)
Maternal
Paternal
ADHD
Father
Mother
Brother
Sister
Children
Aunt
Aunt (ADHD)
Maternal
Paternal
Uncle
Uncle (ADHD)
Maternal
Paternal
Grandparent
Grandparent (ADHD)
Maternal
Paternal
Suicide Attempts
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Suicide Attempts)
Maternal
Paternal
Uncle
Uncle (Suicide Attempts)
Maternal
Paternal
Grandparent
Grandparent (Suicide Attempts)
Maternal
Paternal
Psychiatric Hospitalization
Father
Mother
Brother
Sister
Children
Aunt
Aunt (Psychiatric Hospitalization)
Maternal
Paternal
Uncle
Uncle (Psychiatric Hospitalization)
Maternal
Paternal
Grandparent
Grandparent (Psychiatric Hospitalization)
Maternal
Paternal
Past Psychiatric Medications (if you have ever taken any of the following medications, indicate the date, dosage, and how helpful they were)
Antidepressants: Prozac (fluoxetine)
Antidepressants: Prozac (fluoxetine)
Check if taken
Antidepressants: Prozac (fluoxetine)
When
Antidepressants: Prozac (fluoxetine)
Dosage?
Antidepressants: Prozac (fluoxetine)
Did it help?
Yes
No
Antidepressants: Prozac (fluoxetine)
Any side effects?
Yes
No
Antidepressants: Zoloft (sertraline)
Antidepressants: Zoloft (sertraline)
Check if taken
Antidepressants: Zoloft (sertraline)
When
Antidepressants: Zoloft (sertraline)
Dosage ?
Antidepressants: Zoloft (sertraline)
Did it help?
Yes
No
Antidepressants: Zoloft (sertraline)
Any Side Effect ?
Yes
No
Antidepressants: Luvox (fluvoxamine)
Antidepressants: Luvox (fluvoxamine)
Check if taken
Antidepressants: Luvox (fluvoxamine)
When
Antidepressants: Luvox (fluvoxamine)
Dosage ?
Antidepressants: Luvox (fluvoxamine)
Did it help?
Yes
No
Antidepressants: Luvox (fluvoxamine)
Any Side Effect ?
Yes
No
Antidepressants: Paxil (paroxetine)
Antidepressants: Paxil (paroxetine)
Check if taken
Antidepressants: Paxil (paroxetine)
When
Antidepressants: Paxil (paroxetine)
Dosage ?
Antidepressants: Paxil (paroxetine)
Did it help?
Yes
No
Antidepressants: Paxil (paroxetine)
Any Side Effect ?
Yes
No
Antidepressants: Celexa (citalopram)
Antidepressants: Celexa (citalopram)
Check if taken
Antidepressants: Celexa (citalopram)
When
Antidepressants: Celexa (citalopram)
Dosage ?
Antidepressants: Celexa (citalopram)
Did it help?
Yes
No
Antidepressants: Celexa (citalopram)
Any Side Effect ?
Yes
No
Antidepressants: Effexor (venlafaxine)
Antidepressants: Effexor (venlafaxine)
Check if taken
Antidepressants: Effexor (venlafaxine)
When
Antidepressants: Effexor (venlafaxine)
Dosage ?
Antidepressants: Effexor (venlafaxine)
Did it help?
Yes
No
Antidepressants: Effexor (venlafaxine)
Any Side Effect ?
Yes
No
Antidepressants: Cymbalta (duloxetine)
Antidepressants: Cymbalta (duloxetine)
Check if taken
Antidepressants: Cymbalta (duloxetine)
When
Antidepressants: Cymbalta (duloxetine)
Dosage ?
Antidepressants: Cymbalta (duloxetine)
Did it help?
Yes
No
Antidepressants: Cymbalta (duloxetine)
Any Side Effect ?
Yes
No
Antidepressants: Wellbutrin (bupropion)
Antidepressants: Wellbutrin (bupropion)
Check if taken
Antidepressants: Wellbutrin (bupropion)
When
Antidepressants: Wellbutrin (bupropion)
Dosage ?
Antidepressants: Wellbutrin (bupropion)
Did it help?
Yes
No
Antidepressants: Wellbutrin (bupropion)
Any Side Effect ?
Yes
No
Antidepressants: Remeron (mirtazapine)
Antidepressants: Remeron (mirtazapine)
Check if taken
Antidepressants: Remeron (mirtazapine)
When
Antidepressants: Remeron (mirtazapine)
Dosage ?
Antidepressants: Remeron (mirtazapine)
Did it help?
Yes
No
Antidepressants: Remeron (mirtazapine)
Any Side Effect ?
Yes
No
Antidepressants: Serzone (nefazodone)
Antidepressants: Serzone (nefazodone)
Check if taken
Antidepressants: Serzone (nefazodone)
When
Antidepressants: Serzone (nefazodone)
Dosage ?
Antidepressants: Serzone (nefazodone)
Did it help?
Yes
No
Antidepressants: Serzone (nefazodone)
Any Side Effect ?
Yes
No
Antidepressants: Anafranil (clomipramine)
Antidepressants: Anafranil (clomipramine)
Check if taken
Antidepressants: Anafranil (clomipramine)
When
Antidepressants: Anafranil (clomipramine)
Dosage ?
Antidepressants: Anafranil (clomipramine)
Did it help?
Yes
No
Antidepressants: Anafranil (clomipramine)
Any Side Effect ?
Yes
No
Antidepressants: Pamelor (nortrptyline)
Antidepressants: Pamelor (nortrptyline)
Check if taken
Antidepressants: Pamelor (nortrptyline)
When
Antidepressants: Pamelor (nortrptyline)
Dosage ?
Antidepressants: Pamelor (nortrptyline)
Did it help?
Yes
No
Antidepressants: Pamelor (nortrptyline)
Any Side Effect ?
Yes
No
Antidepressants: Tofranil (imipramine)
Antidepressants: Tofranil (imipramine)
Check if taken
Antidepressants: Tofranil (imipramine)
When
Antidepressants: Tofranil (imipramine)
Dosage ?
Antidepressants: Tofranil (imipramine)
Did it help?
Yes
No
Antidepressants: Tofranil (imipramine)
Any Side Effect ?
Yes
No
Antidepressants: Elavil (amitriptyline)
Antidepressants: Elavil (amitriptyline)
Check if taken
Antidepressants: Elavil (amitriptyline)
When
Antidepressants: Elavil (amitriptyline)
Dosage ?
Antidepressants: Elavil (amitriptyline)
Did it help?
Yes
No
Antidepressants: Elavil (amitriptyline)
Any Side Effect ?
Yes
No
Antidepressants: Pristiq (desvenlafaxin)
Antidepressants: Pristiq (desvenlafaxin)
Check if taken
Antidepressants: Pristiq (desvenlafaxin)
When
Antidepressants: Pristiq (desvenlafaxin)
Dosage ?
Antidepressants: Pristiq (desvenlafaxin)
Did it help?
Yes
No
Antidepressants: Pristiq (desvenlafaxin)
Any Side Effect ?
Yes
No
Antidepressants: Desyrel (trazadone)
Antidepressants: Desyrel (trazadone)
Check if taken
Antidepressants: Desyrel (trazadone)
When
Antidepressants: Desyrel (trazadone)
Dosage ?
Antidepressants: Desyrel (trazadone)
Did it help?
Yes
No
Antidepressants: Desyrel (trazadone)
Any Side Effect ?
Yes
No
Antidepressants: Viibryd (vilazodone)
Antidepressants: Viibryd (vilazodone)
Check if taken
Antidepressants: Viibryd (vilazodone)
When
Antidepressants: Viibryd (vilazodone)
Dosage ?
Antidepressants: Viibryd (vilazodone)
Did it help?
Yes
No
Antidepressants: Viibryd (vilazodone)
Any Side Effect ?
Yes
No
Antidepressants: Adapin (doxepin)
Antidepressants: Adapin (doxepin)
Check if taken
Antidepressants: Adapin (doxepin)
When
Antidepressants: Adapin (doxepin)
Dosage ?
Antidepressants: Adapin (doxepin)
Did it help?
Yes
No
Antidepressants: Adapin (doxepin)
Any Side Effect ?
Yes
No
Antidepressants: Asendin (amoxapine)
Antidepressants: Asendin (amoxapine)
Check if taken
Antidepressants: Asendin (amoxapine)
When
Antidepressants: Asendin (amoxapine)
Dosage ?
Antidepressants: Asendin (amoxapine)
Did it help?
Yes
No
Antidepressants: Asendin (amoxapine)
Any Side Effect ?
Yes
No
Antidepressants: Ludiomil (maprotiline)
Antidepressants: Ludiomil (maprotiline)
Check if taken
Antidepressants: Ludiomil (maprotiline)
When
Antidepressants: Ludiomil (maprotiline)
Dosage ?
Antidepressants: Ludiomil (maprotiline)
Did it help?
Yes
No
Antidepressants: Ludiomil (maprotiline)
Any Side Effect ?
Yes
No
Antidepressants: Norpramin (desipramine)
Antidepressants: Norpramin (desipramine)
Check if taken
Antidepressants: Norpramin (desipramine)
When
Antidepressants: Norpramin (desipramine)
Dosage ?
Antidepressants: Norpramin (desipramine)
Did it help?
Yes
No
Antidepressants: Norpramin (desipramine)
Any Side Effect ?
Yes
No
Antidepressants: Surmontil (trimipramine)
Antidepressants: Surmontil (trimipramine)
Check if taken
Antidepressants: Surmontil (trimipramine)
When
Antidepressants: Surmontil (trimipramine)
Dosage ?
Antidepressants: Surmontil (trimipramine)
Did it help?
Yes
No
Antidepressants: Surmontil (trimipramine)
Any Side Effect ?
Yes
No
Antidepressants: Vivactil (protriptyline)
Antidepressants: Vivactil (protriptyline)
Check if taken
Antidepressants: Vivactil (protriptyline)
When
Antidepressants: Vivactil (protriptyline)
Dosage ?
Antidepressants: Vivactil (protriptyline)
Did it help?
Yes
No
Antidepressants: Vivactil (protriptyline)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
Check if taken
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
When
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
Dosage ?
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Zyprexa (olanzapine)
Antipsychotics/Mood Stabilizers: Seroquel (quetiapine)
Check if taken
Antipsychotics/Mood Stabilizers: Zyprexa (olanzapine)
When
Antipsychotics/Mood Stabilizers: Zyprexa (olanzapine)
Dosage ?
Antipsychotics/Mood Stabilizers: Zyprexa (olanzapine)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Zyprexa (olanzapine)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Geodon (ziprasidone)
Antipsychotics/Mood Stabilizers: Geodon (ziprasidone)
Check if taken
Antipsychotics/Mood Stabilizers: Geodon (ziprasidone)
When
Antipsychotics/Mood Stabilizers: Geodon (ziprasidone)
Dosage ?
Antipsychotics/Mood Stabilizers: Geodon (ziprasidone)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Geodon (ziprasidone)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Abilify (aripiprazole)
Antipsychotics/Mood Stabilizers: Abilify (aripiprazole)
Check if taken
Antipsychotics/Mood Stabilizers: Abilify (aripiprazole)
When
Antipsychotics/Mood Stabilizers: Abilify (aripiprazole)
Dosage ?
Antipsychotics/Mood Stabilizers: Abilify (aripiprazole)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Abilify (aripiprazole)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Clozaril (clozapine)
Antipsychotics/Mood Stabilizers: Clozaril (clozapine)
Check if taken
Antipsychotics/Mood Stabilizers: Clozaril (clozapine)
When
Antipsychotics/Mood Stabilizers: Clozaril (clozapine)
Dosage ?
Antipsychotics/Mood Stabilizers: Clozaril (clozapine)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Clozaril (clozapine)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Haldol (haloperidol)
Antipsychotics/Mood Stabilizers: Haldol (haloperidol)
Check if taken
Antipsychotics/Mood Stabilizers: Haldol (haloperidol)
When
Antipsychotics/Mood Stabilizers: Haldol (haloperidol)
Dosage ?
Antipsychotics/Mood Stabilizers: Haldol (haloperidol)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Haldol (haloperidol)
Any Side Effect ?
Yes
No
Antipsychotics/Mood Stabilizers: Prolixin (fluphenazine)
Antipsychotics/Mood Stabilizers: Prolixin (fluphenazine)
Check if taken
Antipsychotics/Mood Stabilizers: Prolixin (fluphenazine)
When
Antipsychotics/Mood Stabilizers: Prolixin (fluphenazine)
Dosage ?
Antipsychotics/Mood Stabilizers: Prolixin (fluphenazine)
Did it help?
Yes
No
Antipsychotics/Mood Stabilizers: Prolixin (fluphenazine)
Any Side Effect ?
Yes
No
Sedative/Hypnotics: Ambien (zolpidem)
Sedative/Hypnotics: Ambien (zolpidem)
Check if taken
Sedative/Hypnotics: Ambien (zolpidem)
When
Sedative/Hypnotics: Ambien (zolpidem)
Dosage ?
Sedative/Hypnotics: Ambien (zolpidem)
Did it help?
Yes
No
Sedative/Hypnotics: Ambien (zolpidem)
Any Side Effect ?
Yes
No
Sedative/Hypnotics: Sonata (zaleplon)
Sedative/Hypnotics: Sonata (zaleplon)
Check if taken
Sedative/Hypnotics: Sonata (zaleplon)
When
Sedative/Hypnotics: Sonata (zaleplon)
Dosage ?
Sedative/Hypnotics: Sonata (zaleplon)
Did it help?
Yes
No
Sedative/Hypnotics: Sonata (zaleplon)
Any Side Effect ?
Yes
No
Sedative/Hypnotics: Restoril (temazepam)
Sedative/Hypnotics: Restoril (temazepam)
Check if taken
Sedative/Hypnotics: Restoril (temazepam)
When
Sedative/Hypnotics: Restoril (temazepam)
Dosage ?
Sedative/Hypnotics: Restoril (temazepam)
Did it help?
Yes
No
Sedative/Hypnotics: Restoril (temazepam)
Any Side Effect ?
Yes
No
Sedative/Hypnotics: Rozerem (ramelteon)
Sedative/Hypnotics: Rozerem (ramelteon)
Check if taken
Sedative/Hypnotics: Rozerem (ramelteon)
When
Sedative/Hypnotics: Rozerem (ramelteon)
Dosage ?
Sedative/Hypnotics: Rozerem (ramelteon)
Did it help?
Yes
No
Sedative/Hypnotics: Rozerem (ramelteon)
Any Side Effect ?
Yes
No
Sedative/Hypnotics: Desyrel (trazodone)
Sedative/Hypnotics: Desyrel (trazodone)
Check if taken
Sedative/Hypnotics: Desyrel (trazodone)
When
Sedative/Hypnotics: Desyrel (trazodone)
Dosage ?
Sedative/Hypnotics: Desyrel (trazodone)
Did it help?
Yes
No
Sedative/Hypnotics: Desyrel (trazodone)
Any Side Effect ?
Yes
No
ADHD Medications: Adderall (amphetamine)
ADHD Medications: Adderall (amphetamine)
Check if taken
ADHD Medications: Adderall (amphetamine)
When
ADHD Medications: Adderall (amphetamine)
Dosage ?
ADHD Medications: Adderall (amphetamine)
Did it help?
Yes
No
ADHD Medications: Adderall (amphetamine)
Any Side Effect?
Yes
No
ADHD Medications: Concerta (methylphenidate)
ADHD Medications: Adderall (amphetamine)
Check if taken
ADHD Medications: Concerta (methylphenidate)
When
ADHD Medications: Concerta (methylphenidate)
Dosage ?
ADHD Medications: Concerta (methylphenidate)
Did it help?
Yes
No
ADHD Medications: Concerta (methylphenidate)
Any Side Effect?
Yes
No
ADHD Medications: Ritalin (methylphenidate)
ADHD Medications: Ritalin (methylphenidate)
Check if taken
ADHD Medications: Ritalin (methylphenidate)
When
ADHD Medications: Ritalin (methylphenidate)
Dosage ?
ADHD Medications: Ritalin (methylphenidate)
Did it help?
Yes
No
ADHD Medications: Ritalin (methylphenidate)
Any Side Effect?
Yes
No
ADHD Medications: Strattera (atomoxetine)
ADHD Medications: Strattera (atomoxetine)
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ADHD Medications: Strattera (atomoxetine)
When
ADHD Medications: Strattera (atomoxetine)
Dosage ?
ADHD Medications: Strattera (atomoxetine)
Did it help?
Yes
No
ADHD Medications: Strattera (atomoxetine)
Any Side Effect?
Yes
No
Antianxiety Medications: Xanax (alprazolam)
Antianxiety Medications: Xanax (alprazolam)
Check if taken
Antianxiety Medications: Xanax (alprazolam)
When
Antianxiety Medications: Xanax (alprazolam)
Dosage ?
Antianxiety Medications: Xanax (alprazolam)
Did it help?
Yes
No
Antianxiety Medications: Xanax (alprazolam)
Any Side Effect?
Yes
No
Antianxiety Medications: Ativan (lorazepam)
Antianxiety Medications: Ativan (lorazepam)
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Antianxiety Medications: Ativan (lorazepam)
When
Antianxiety Medications: Ativan (lorazepam)
Dosage ?
Antianxiety Medications: Ativan (lorazepam)
Did it help?
Yes
No
Antianxiety Medications: Ativan (lorazepam)
Any Side Effect?
Yes
No
Antianxiety Medications: Klonopin (clonazepam)
Antianxiety Medications: Klonopin (clonazepam)
Check if taken
Antianxiety Medications: Klonopin (clonazepam)
When
Antianxiety Medications: Klonopin (clonazepam)
Dosage ?
Antianxiety Medications: Klonopin (clonazepam)
Did it help?
Yes
No
Antianxiety Medications: Klonopin (clonazepam)
Any Side Effect?
Yes
No
Antianxiety Medications: Valium (diazepam)
Antianxiety Medications: Valium (diazepam)
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Antianxiety Medications: Valium (diazepam)
When
Antianxiety Medications: Valium (diazepam)
Dosage ?
Antianxiety Medications: Valium (diazepam)
Did it help?
Yes
No
Antianxiety Medications: Valium (diazepam)
Any Side Effect?
Yes
No
Antianxiety Medications: Tranxene (clorazepate)
Antianxiety Medications: Tranxene (clorazepate)
Check if taken
Antianxiety Medications: Tranxene (clorazepate)
When
Antianxiety Medications: Tranxene (clorazepate)
Dosage ?
Antianxiety Medications: Tranxene (clorazepate)
Did it help?
Yes
No
Antianxiety Medications: Tranxene (clorazepate)
Any Side Effect?
Yes
No
Antianxiety Medications: Buspar (buspirone)
Antianxiety Medications: Buspar (buspirone)
Check if taken
Antianxiety Medications: Buspar (buspirone)
When
Antianxiety Medications: Buspar (buspirone)
Dosage ?
Antianxiety Medications: Buspar (buspirone)
Did it help?
Yes
No
Antianxiety Medications: Buspar (buspirone)
Any Side Effect?
Yes
No
Other Medications (specify)
Other Medications (specify): When
Other Medications (specify): Dosage
Other Medications (specify): Did it help?
Yes
No
Other Medications (specify): Any Side Effect?
Yes
No
Other Medications (specify)
Other Medications (specify): When
Other Medications (specify): Dosage
Other Medications (specify): Did it help?
Yes
No
Other Medications (specify): Any Side Effect?
Yes
No
Other Medications (specify)
Other Medications (specify): When
Other Medications (specify): Dosage
Other Medications (specify): Did it help?
Yes
No
Other Medications (specify): Any Side Effect?
Yes
No
SUBSTANCE USE HISTORY
Substance Use Status:
No history of abuse
Active abuse
Early full remission
Early partial remission
Sustained full remission
Sustained partial remission
Treatment History:
Outpatient
Inpatient
12-step program
Stopped on own
Other:
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