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Date
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Date
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Date Submitted
Patient's Last Name*
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Date of Birth*
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Date of Birth* This field is hidden when viewing the form
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Age*
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We apologize for the inconvenience, we only see patients 16 years of age or older. This field is hidden when viewing the form
Do you have an open legal case or court case? Workers Compensation or Child Protective Services (CPS) Hearing?* We apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment. This field is hidden when viewing the form
Are you already ON any pain-control medication such as Hydrocodone, Percocet, Tylenol w/ Codeine, Pain-controlling patches, Opioids, etc.? Please be advised that we will NOT be able to prescribe any Benzodiazepines such as Xanax, Klonopin, Valium, or Ativan due to DEA regulations.* Please contact our Appointment Team at 817-488-8998 ext 2 to further assist you. I understand that Mid Cities Psychiatry may request a Urine Drug Screen, which I must provide either at Mid Cities Psychiatry's office or at an accredited laboratory within 48 hours of their request. If the screen detects substances not prescribed (including THC, Delta 8, Kratom, and Alcohol) or if it shows a lack of prescribed medications, Mid Cities Psychiatry reserves the right to decline any further prescriptions.* This field is hidden when viewing the form
I acknowledge that coming to appointment does not guarantee that control-medication will be prescribed. It’s up to the Provider’s discretion when they meet the patient.* I acknowledge that eligibility for a FormFill Appointment requires a minimum of 5 previous appointments and an association with the clinic for at least 5 months. I will not request a FormFill Appointment if I do not meet these criteria, specifically if: I have been associated with the clinic for 5 months but have had fewer than 5 appointments, or I have had 5 appointments but my association with the clinic is under 5 months.* This field is hidden when viewing the form
I acknowledge Mid Cities Psychiatry's policy for rescheduling, canceling, and no-shows. I must inform Mid Cities Psychiatry at least 24 business hours before my appointment for changes. Weekends, long weekends, and national holidays are excluded as they are non-business hours. Non-compliance will incur charges as per the RCN Fee Schedule:
• 40 minutes meds management appointment no-show fees would be $150.00
An appointment Rescheduled or Canceled within 24 business hours of your appointment or No-Show at the appointment will be billed as per the following RCN Fee Schedule. Please be advised calls made 24 hours before the appointment on weekends or long weekends or on National Holidays when our offices are closed are not 24 Business Hours. So to avoid our billing department billing you RCN Fee, please call in more than 24 business hours.* RCN (Rescheduling / Cancellation / No-Shows) Policy:
My Contact Information Cell Number*
Home Number
Email*
Street Address*
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City*
State*
Zip/Postal Code*
My Insurance Insurance Please upload your Identification Please select the type of identification you would like to use.* Select Option Driver’s License Government ID Passport/Passport Card
Please provide the front image of your identification in PDF or JPG format. Please provide the back image of your identification in PDF or JPG format.
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Primary Insurance Primary Insurance* Select Primary Insurance Aetna Allsaver Ambetter From Superior Health Plan American Behavioral Health Blue Cross Blue Shield Bright HealthCare Care Improvement Plan Care N Care Cigna CompSych GHI - BMP Golden Rule Group and Pension Administrator(GPA) HealthScope HealthSmart (Network) Humana Magellan Behavioral Health Medicare Molina Texas Healthcare Mulitiplan (Network) Mutual of Omaha Medicare Advantage Plan New Era Life Insurance PHCS (Network) Scott & White Health Plan Silver Back TPA Tricare East Region Tricare For Life Triwest UMR United HealthCare Other Insurance
Other Insurance*
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Primary Insurance ID #*
Primary Insurance Group #
Please upload your Insurance card Please provide the front image of your Insurance Card in PDF or JPG format. Please provide the back image of your Insurance Card in PDF or JPG format.
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Secondary Insurance Secondary Insurance Select Secondary Insurance N/A Aetna Allsaver Ambetter From Superior Health Plan American Behavioral Health Blue Cross Blue Shield Care Improvement Plan Care N Care Cigna CompSych GHI - BMP Golden Rule Group and Pension Administrator(GPA) HealthScope HealthSmart (Network) Humana Magellan Behavioral Health Medicare Molina Texas Healthcare Mulitiplan (Network) Mutual of Omaha Medicare Advantage Plan New Era Life Insurance PHCS (Network) Scott & White Health Plan Silver Back TPA Tricare East Region Tricare For Life Triwest UMR United HealthCare
Secondary Insurance ID #
Secondary Insurance Group #
Please upload your Identification Please select the type of identification you would like to use.* Select Option Driver’s License Government ID Passport/Passport Card
Please provide the front image of your identification in PDF or JPG format. Please provide the back image of your identification in PDF or JPG format.
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How Did You Hear About Us* Select Option Blog or Publication Customer Testimonials Referred by a Friend Referred by a Provider Referred by our Patient Search Engine (Google, Yahoo, etc.) Social Media (Twitter, Facebook, LinedIn)
Name*
Specialty*
Phone Number*
Fax Number*
Appointment Reason Appointment Reason* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Esketamine (Sparavto) Ketamine Mood Disorders Obsessive-Compulsive-Disorder (OCD) Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS Other
Other Reason*
Appointment Reason Description*
Goals What is your short term treatment goal?
What is your long term treatment goal?
Suicidal Ideation In the past month
Have you wished you were dead or wished you could go to sleep and not wake up?* Have you actually had any thoughts of killing yourself?* Have you been thinking about how you might do this?* Have you had these thoughts and had some intention of acting on them?* Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?* Have you ever done anything, started to do anything, or prepared to do anything to end your life?* Was this within the past three months?* This field is hidden when viewing the form
Patients categorized as
Homicidal Ideations Are you having Homicidal Ideations?* Do You Have a Plan?* What is your plan?*
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Dependent Care Resources Dependent Care Resources This field is hidden when viewing the form
Do you need resources for the care of your dependents?* This field is hidden when viewing the form
Psychiatric Advance Directive Question: Psychiatric Advance Directive This field is hidden when viewing the form
Do you have a Psychiatric Advance Directive?* This field is hidden when viewing the form
Please attach it here This field is hidden when viewing the form
Would you like to create one?* This field is hidden when viewing the form
Legal Need Resources Question Legal Need Resources This field is hidden when viewing the form
Are you in need of legal assistance or support?* This field is hidden when viewing the form
Vocational Need Resources Question Vocational Need Resources This field is hidden when viewing the form
Do you need vocational assistance or support?* This field is hidden when viewing the form
Generalized Anxiety Disorder Questionnaire ( GAD-7 ) How often have you been bothered by the following problems? As you answer each question, select the radio button that best describes how you have felt and conducted yourself over the past 2 weeks. This field is hidden when viewing the form
1. Feeling nervous, anxious or on edge?* This field is hidden when viewing the form
2. Not being able to stop or control worrying?* This field is hidden when viewing the form
3. Worrying too much about different things?* This field is hidden when viewing the form
4. Trouble relaxing?* This field is hidden when viewing the form
5. Being so restless that it is hard to sit still?* This field is hidden when viewing the form
6. Becoming easily annoyed or irritable?* This field is hidden when viewing the form
7. Feeling afraid as if something awful might happen?* This field is hidden when viewing the form
If you checked off any of the problems, Not difficult at all how difficult have these problems made it for you to do your work, Somewhat difficult take care of things at home, Very difficult or get along with other people? * Select Option Not difficult at all Somewhat difficult Very difficult Extremely difficult
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If you checked off any of the problems, Not difficult at all how difficult have these problems made it for you to do your work, Somewhat difficult take care of things at home, Very difficult or get along with other people? * Select Option Not difficult at all Somewhat difficult Very difficult Extremely difficult
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Your GAD Scale Total Score Is
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Anxiety level based on score is
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Anxiety level based on score is
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Anxiety level based on score is
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Anxiety level based on score is
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Anxiety level based on score is
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Have you done Connors (ADHD) Testing or Personality Assessment Inventory Testing before? Both these tests are computer-based psychological evaluations designed to measure cognitive abilities, personality traits, emotional states, and behaviors.* Please make sure to submit your previous Connors (ADHD) Testing or Personality Assessment Inventory results soon after your appointment is scheduled This field is hidden when viewing the form
Are you interested in learning more about Connors (ADHD) Testing or Personality Assessment Inventory Testing?* This field is hidden when viewing the form
Rapid Mood Screener (RMS) Are you among the millions of people who have depressive symptoms? Answer the following questionnaire about your medical history so that it can be provided to your provider or nurse to assist in an important conversation about your mood. Please select one response for each question. You can complete the RMS in less than 2 minutes. This field is hidden when viewing the form
1. Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?* This field is hidden when viewing the form
2. Did you have problems with depression before the age of 18?* This field is hidden when viewing the form
3. Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?* This field is hidden when viewing the form
4. Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?* This field is hidden when viewing the form
5. Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?* This field is hidden when viewing the form
6. Have you ever had a period of at least 1 week during which you needed much less sleep than usual?* This field is hidden when viewing the form
Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF) During the past week how satisfied have you been with your: This field is hidden when viewing the form
1. Physical health?* This field is hidden when viewing the form
2. Mood?* This field is hidden when viewing the form
3. Work?* This field is hidden when viewing the form
4. Household activities?* This field is hidden when viewing the form
5. Social relationships?* This field is hidden when viewing the form
6. Family relationships?* This field is hidden when viewing the form
7. Leisure time activities?* This field is hidden when viewing the form
8. Ability to function in daily life?* This field is hidden when viewing the form
9. Sexual drive, interest and/or performance?* This field is hidden when viewing the form
In what aspect of your Sexual drive, interest and/or performance?*
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10. Economic status?* This field is hidden when viewing the form
11. Living/housing situation?* This field is hidden when viewing the form
In what aspect of your Living/housing situation?*
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12. Ability to get around physically without feeling dizzy or unsteady or falling?* This field is hidden when viewing the form
In what aspect of your vision in terms of ability to get around physically without feeling dizzy or unsteady or falling?*
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13. Your vision in terms of ability to do work or hobbies?* This field is hidden when viewing the form
In what aspect of your vision in terms of ability to do work or hobbies?*
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14. Overall sense of well being?* This field is hidden when viewing the form
15. Medication? (If not taking any, just leave item blank.) This field is hidden when viewing the form
16. How would you rate your overall life satisfaction and contentment during the past week?* This field is hidden when viewing the form
PIF This field is hidden when viewing the form
Previous Psychiatric Diagnosis This field is hidden when viewing the form
Have you been previously diagnosed with a psychiatric disorder?* This field is hidden when viewing the form
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Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Other Reason*
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Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-2 This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Other Reason*
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Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-3 This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Other Reason*
Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-4 This field is hidden when viewing the form
Diagnosis* Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Other Reason*
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Do you have an Additional Previous Psychiatric Diagnosis?* This field is hidden when viewing the form
PPD-5 This field is hidden when viewing the form
Diagnosis * Select Appointment Reason Addiction Anxiety Attention-Deficit / Hyperactivity Disorder (ADHD) Autism Spectrum Disorder (ASD) (not testing) Bipolar / Mood Disorders Dementia Depression Eating Disorders Mood Disorders Obsessive-Compulsive-Disorder (OCD) Other Personality Disorders Phobias Post-Traumatic-Stress-Disorder (PTSD) Psychosis Psychotic Disorders / Schizophrenia Schizophrenia & Schizoaffective Disorders Seasonal Affective Disorder Substance Use Disorder TMS
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Year Diagnosed * Choose a year 1910
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Treating Provider*
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Other Reason*
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Previous Psychiatric Hospitalizations and/or Rehabilitation This field is hidden when viewing the form
Have you previously been hospitalized with a psychiatric disorder and/or attended a rehabilitation facility?* This field is hidden when viewing the form
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Hospital/Rehab Name*
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Year* Choose a year 1910
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Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-1 This field is hidden when viewing the form
Hospital/Rehab Name*
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Year* Choose a year 1910
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Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-2 This field is hidden when viewing the form
Hospital/Rehab Name*
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Year* Choose a year 1910
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Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-3 This field is hidden when viewing the form
Hospital/Rehab Name*
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Year* Choose a year 1910
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Do you have additional Previous Psychiatric Hospitalizations/Rehab? This field is hidden when viewing the form
PPHR-4 This field is hidden when viewing the form
Hospital/Rehab Name*
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Year* Choose a year 1910
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Previous Psychiatric/Sleep Medications This field is hidden when viewing the form
Have you previously been prescribed any Psychiatric/Sleep Medications?* This field is hidden when viewing the form
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Medications Name*
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Dose*
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Start Date *
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End Date *
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Side Effects*
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Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-2 This field is hidden when viewing the form
Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
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Side Effects*
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Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-3 This field is hidden when viewing the form
Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-4 This field is hidden when viewing the form
Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-5 This field is hidden when viewing the form
Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-6 This field is hidden when viewing the form
Medications Name*
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Dose*
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Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Do you have additional Medication?* This field is hidden when viewing the form
PPSMM-7 This field is hidden when viewing the form
Medications Name*
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Dose*
Start Date *
MM slash DD slash YYYY
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End Date *
MM slash DD slash YYYY
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Side Effects*
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Medication Allergies This field is hidden when viewing the form
Do you have any Medication Allergies?* This field is hidden when viewing the form
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Name*
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Reaction*
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Do you have an additional Medication Allergies?* This field is hidden when viewing the form
MA-2 This field is hidden when viewing the form
Name*
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Reaction*
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Pharmacy This field is hidden when viewing the form
Do you have a Pharmacy?* This field is hidden when viewing the form
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Name*
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City*
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State*
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Phone #*
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Do you have an Additional Pharmacy?* This field is hidden when viewing the form
Pharmacy-2 This field is hidden when viewing the form
Name *
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City *
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State *
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Phone #*
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Self Medical History This field is hidden when viewing the form
Do you have medical history (seizures disorders, diabetes, heart problems, other)?* This field is hidden when viewing the form
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Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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SMH-2 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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SMH-3 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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SMH-4 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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SMH-5 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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SMH-6 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Physical Pain This field is hidden when viewing the form
Have you had physical pain in the last week?* This field is hidden when viewing the form
On this scale how bad was your pain? (0 is none and 10 is severe)* This field is hidden when viewing the form
Do you currenty have physical pain now?* This field is hidden when viewing the form
On this scale how bad was your pain? (0 is none and 10 is severe)* This field is hidden when viewing the form
Nutritional Status This field is hidden when viewing the form
1. Do you have food allergies?* This field is hidden when viewing the form
2. Have you had weight loss or gain of 10 pounds or more in the last 3 months?* This field is hidden when viewing the form
3. Have you had a decrease in food intake and/or appetite?* This field is hidden when viewing the form
4. Do you have dental problems?* This field is hidden when viewing the form
5. Do you have eating habits or behaviors that may be indicators of an eating disorder, such as binging or inducing vomiting?* This field is hidden when viewing the form
What are they?*
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Nutritional Status Score Is (this field is to be hidden)
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You are identified as
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You are identified as
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You are identified as
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You are identified as
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You are identified as
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You are identified as
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Self Psychiatric History This field is hidden when viewing the form
Do you have psychiatric history?* This field is hidden when viewing the form
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Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-2 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-3 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-4 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-5 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Do you have additional psychiatric history?* This field is hidden when viewing the form
SPH-6 This field is hidden when viewing the form
Diagnosis*
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Year Diagnosed* Choose a year 1910
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Treating Provider*
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Have you ever experienced trauma?* This field is hidden when viewing the form
What trauma have you experienced?*
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Have you ever experienced abuse?* This field is hidden when viewing the form
What abuse have you experienced?*
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Have you ever experienced neglect?* This field is hidden when viewing the form
What neglect have you experienced?*
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Have you ever been exploited?* This field is hidden when viewing the form
How have you been exploited?*
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Family Medical History This field is hidden when viewing the form
Do you have biological family members with a medical history (seizures disorders, diabetes, heart problems, other)?* This field is hidden when viewing the form
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Relationship* Select Relationship Brother Daugther Father Mother Sister Son
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Living/Passed* Select Option Living Passed
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Age*
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Medical History*
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Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-2 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
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Living/Passed* Select Option Living Passed
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Age*
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Medical History*
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Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-3 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
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Living/Passed* Select Option Living Passed
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Age*
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Medical History*
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Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-4 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
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Living/Passed* Select Option Living Passed
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Age*
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Medical History*
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Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-5 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
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Living/Passed* Select Option Living Passed
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Age*
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Medical History*
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Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-6 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
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Living/Passed* Select Option Living Passed
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Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-7 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-8 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-9 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Medical History*
This field is hidden when viewing the form
Do you have any additional biological family members with medical history?* This field is hidden when viewing the form
FMH-10 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
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Age*
This field is hidden when viewing the form
Medical History*
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Family Psychiatric History This field is hidden when viewing the form
Do you have any biological family members with psychiatric history?* This field is hidden when viewing the form
This field is hidden when viewing the form
Relationship* Select Relationship Brother Daugther Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
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Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-2 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
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Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-3 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
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Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-4 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-5 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-6 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-7 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-8 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-9 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
This field is hidden when viewing the form
Age*
This field is hidden when viewing the form
Psychiatric History*
This field is hidden when viewing the form
Do you have any additional biological family members with psychiatric history?* This field is hidden when viewing the form
FPH-10 This field is hidden when viewing the form
Relationship* Select Relationship Brother Daughter Father Mother Sister Son
This field is hidden when viewing the form
Living/Passed* Select Option Living Passed
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Age*
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Psychiatric History*
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Past Surgical History This field is hidden when viewing the form
Have you had any surgeries in the past?* This field is hidden when viewing the form
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Procedure*
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Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
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Do you have an Additional Past Surgical History?* This field is hidden when viewing the form
PSH-2 This field is hidden when viewing the form
Procedure*
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Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
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Do you have an Additional Past Surgical History?* This field is hidden when viewing the form
PSH-3 This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
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Do you have an Additional Past Surgical History?* This field is hidden when viewing the form
PSH-4 This field is hidden when viewing the form
Procedure*
This field is hidden when viewing the form
Date Of Procedure
MM slash DD slash YYYY
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Provider Name*
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Legal History This field is hidden when viewing the form
Do you have a Current or Previous Conviction?* This field is hidden when viewing the form
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Arrest Date
MM slash DD slash YYYY
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Charge*
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Convicted*
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Sentence*
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Do you have an Additional Legal History?* This field is hidden when viewing the form
LH-2 This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
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Charge*
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Convicted*
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Sentence*
This field is hidden when viewing the form
Do you have an Additional Legal History?* This field is hidden when viewing the form
LH-3 This field is hidden when viewing the form
Arrest Date
MM slash DD slash YYYY
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Charge*
This field is hidden when viewing the form
Convicted*
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Sentence*
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Probation This field is hidden when viewing the form
Are you currently on Probation?* This field is hidden when viewing the form
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Parole?*
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Ending Date?
MM slash DD slash YYYY
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Lawsuits This field is hidden when viewing the form
Are you involved in any lawsuits?* This field is hidden when viewing the form
Court Dates This field is hidden when viewing the form
Do you have any upcoming Court Dates?* This field is hidden when viewing the form
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Reason
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Military Service This field is hidden when viewing the form
Do you have a Military Service?* This field is hidden when viewing the form
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What did you do?* This field is hidden when viewing the form
Type*
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How long did you serve?
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Was your Discharge Honorable or Dishonorable?* This field is hidden when viewing the form
Please explain*
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Were you involved in a any combat?* This field is hidden when viewing the form
Please describe Combat experience*
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Are you troubled now by your military experience?* This field is hidden when viewing the form
Please describe your trouble by military experience*
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Previous Substance Abuse This field is hidden when viewing the form
Were you involved in Substance Abuse?* This field is hidden when viewing the form
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Name of Substance*
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What age started using*
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What age stopped using*
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Do you have an additional Substance Abuse?* This field is hidden when viewing the form
PSA-2 This field is hidden when viewing the form
Name of Substance*
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What age started using*
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What age stopped using*
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Do you have an additional Substance Abuse?* This field is hidden when viewing the form
PSA-3 This field is hidden when viewing the form
Name of Substance*
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What age started using*
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What age stopped using*
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Current Substance Abuse This field is hidden when viewing the form
Are you currently involved in Substance Abuse?* This field is hidden when viewing the form
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Name of Substance*
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Age started?*
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Quantity*
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Do you have an additional Substance Abuse?* This field is hidden when viewing the form
CSA-2 This field is hidden when viewing the form
Name of Substance*
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Age started?*
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Quantity*
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Do you have an additional Substance Abuse?* This field is hidden when viewing the form
CSA-3 This field is hidden when viewing the form
Name of Substance*
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Age started?*
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Quantity*
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Nicotine This field is hidden when viewing the form
Do you use nicotine products?* This field is hidden when viewing the form
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What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
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Other*
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This field is hidden when viewing the form
What age started using*
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What age stopped using*
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Frequency*
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Do you use any other nicotine products?* This field is hidden when viewing the form
N-2 This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
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Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
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What age stopped using*
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Frequency*
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Do you use any other nicotine products?* This field is hidden when viewing the form
N-3 This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
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Other*
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This field is hidden when viewing the form
What age started using*
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What age stopped using*
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Frequency*
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Do you use any other nicotine products?* This field is hidden when viewing the form
N-4 This field is hidden when viewing the form
What type of nicotine products do you use?* Select Product Chewing Cigarettes Patches Smokeless Tobacco Other
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Other*
This field is hidden when viewing the form
This field is hidden when viewing the form
What age started using*
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What age stopped using
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Frequency*
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Vape This field is hidden when viewing the form
Do you Vape?* This field is hidden when viewing the form
Drink This field is hidden when viewing the form
Do you drink alcohol?* This field is hidden when viewing the form
Alcohol Screening Questionnaire ( AUDIT ) Our clinic asks all patients about alcohol use at least once a year. Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below. This field is hidden when viewing the form
1. How often do you have a drink containing alcohol?* This field is hidden when viewing the form
2. How many drinks containing alcohol do you have on a typical day when you are drinking?* This field is hidden when viewing the form
3. How often do you have four or more drinks on one occasion* This field is hidden when viewing the form
4. How often during the last year have you found that you were not able to stop drinking once you had started?* This field is hidden when viewing the form
5. How often during the last year have you failed to do what was normally expected of you because of drinking?* This field is hidden when viewing the form
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?* This field is hidden when viewing the form
7. How often during the last year have you had a feeling of guilt or remorse after drinking?* This field is hidden when viewing the form
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?* This field is hidden when viewing the form
9. Have you or someone else been injured because of your drinking?* This field is hidden when viewing the form
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?* This field is hidden when viewing the form
What age started using*
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What age stopped using
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Are you currently, or have you previously received treatment for an alcohol problem?* This field is hidden when viewing the form
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Have you ever been in treatment for an alcohol problem?* Never Currently In The Past
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Currently This field is hidden when viewing the form
At what location?*
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Frequency of visit*
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When was the last time you had an alcoholic drink?*
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In the past This field is hidden when viewing the form
At what location?*
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What year? Choose a year 1910
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When was the last time you had an alcoholic drink?*
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Social History/Marital Status This field is hidden when viewing the form
Marital Status* Please choose your marital status Single Married Divorced Seperated Widowed
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Social History/Sexual Orientation This field is hidden when viewing the form
Sexual Orientation* Please choose your sexual orientation Asexual Bisexual Gay Heterosexual Lesbian Pansexual
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Gender This field is hidden when viewing the form
Gender* Please choose your gender Male Female Transgender Gender Neutral Non-Binary Choose Not to Disclose
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Education This field is hidden when viewing the form
Have you completed your education?* This field is hidden when viewing the form
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Highest Schooling* Choose your highest schooling High School/GED Associates Bachelors Masters PhD MD/DO
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Employment This field is hidden when viewing the form
Are you Employed?* This field is hidden when viewing the form
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Type of Employment Choose your employment status Full Time Part Time
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Company Name
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Occupation*
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Not-Employed* Choose your option Disabled Retired Unemployed
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Physical Exam Self Assessment This field is hidden when viewing the form
Please rate your Thought Process* Choose your thought process Good Fair Poor
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Please rate your Long Term Memory* Choose your long term memory Good Fair Poor
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Please rate your Short Term Memory* Choose your short term memory Good Fair Poor
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Please rate your Concentration* Choose your concentration Good Fair Poor
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Current Stressors This field is hidden when viewing the form
Do you have Current Stressors?* This field is hidden when viewing the form
Please choose them below:* This field is hidden when viewing the form
Other
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Select the symptoms you are experiencing* This field is hidden when viewing the form
Other
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Hallucinations Hallucinations are defined as sight, sound, smell, taste, or touch that a person believes to be real but is not real. Hallucinations can be caused by nervous system disease, certain drugs, or mental disorders. This field is hidden when viewing the form
Do you have hallucinations?* This field is hidden when viewing the form
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What type of Hallucinations do you experience?* This field is hidden when viewing the form
Delusions A delusion is defined as a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. This field is hidden when viewing the form
Are you Delusional?* This field is hidden when viewing the form
Possession of Gun This field is hidden when viewing the form
Do you own a gun?* Scheduling Your Appointment! Meeting your needs is our top priority. If you don't receive a response from us within 24 business hours, please feel free to reach out
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