Patient History Form Last Name First Name Phone Number (XXX) XXX-XXXX Address (Billing) Email Address Medical Record # Date of Birth? (MM/DD/YYYY) Date of Admission or Evaluation? (MM/DD/YYYY) Reason for Seeking Help? History Of Presenting Crisis. What exactly happened that requires the need for psychiatric services? Current Psychiatrist? Current Therapist? Current Established Diagnosis? Current Psychiatric Medications? Substance Use History? Alcohol Marijuana Benzodiazepine (Xanax Klonopin Valium Lorazepam) Other If other, please list: Past Psychiatric History? Hospitalizations Past self-harm attempts/Suicidality Past Psychiatric Medications: Please describe: What is the patient's family psychiatric history (father / mother / siblings)? What is the patient's Medical History? Current PCP Allergies Current medications for medical problems Hospitalizations Surgeries History of head injury/ loss of consciousness / Seizures Please describe: Has the patient had Abnormal Lab Work? What is the patient's Developmental History (if under 18)? What are the patient's Living Conditions? What Relations are in the patient's life? Who is the patient Nearest to or Best supported by? Spouse Children Parents Siblings Outside (friend, teacher, etc) Is the patient in Education IEP or regular? IEP Regular Other If other, please describe: Describe the patient's school performance What is the patient's Occupational History? Is there a history of abuse or neglect? Is there a Military history? What are the Patient's interests? What is the Patient's legal history?