COMPREHENSIVE NEW PATIENT HEALTH HISTORY QUESTIONAIRE

Psychiatric Nurse Practitoners of Warick
COMPREHENSIVE NEW PATIENT HEALTH HISTORY QUESTIONAIRE

Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is a shorter update form you can use. Please fill in all pages. It is long because it is comprehensive. We really want to know you well so we can properly care for you. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank-you!
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Your Pharmacy. Please include address

CURRENT BEHAVIORAL SYMPTOMS

	MILD.	MODERATE	SEVERE	ADDITIONAL INFORMATION	NONE
AGGRESSION
AGITATION
ANGER
ANXIETY
APPETITE CHANGE
CHANGE IN LIBIDO
COMPULSIONS
CRYING/TEARFUL
CYBER ADDICTION
DELUSIONS
DEPRESSION
DISORIENTATION
DIFFICULTY GETTING OUT OF BED
DIFFICULTY MAKING DECISIONS
DISTRACTABILITY
EATING DISORDER
ELEVATED MOOD
EMOTIONAL TRAUMA
EXCESSIVE ENERGY
FATIGUE
GRIEF
GUILT
GAMBLING
HALLUCINATIONS
HEARING VOICES
HEART PALPITATIONS
HYPERACTIVITY
IMPULSIVITY
IRRITABILITY
JUDGEMENT ERRORS
LONLINESS
LOS OF INTEREST IN ACTIVITIES
MEMORY IMPAIRMENT
MOOD SWINGS
OBSESSIONS
OPPOSITIONAL BEHAVIOR
PANIC ATTACKS
PARANOIA
PHOBIAS/FEARS
PHYSICAL TRAUMA
POOR CONCENTRATION
POOR GROOMING
RACING THOUGHTS
RECURRING THOUGHTS
SELF MUTILATION
SEXUAL ADDICTION
SEXUAL DIFFICULTIES
SEXUAL TRAUMA
SLEEP PROBLEMS
SPEECH PROBLEMS
SOCIAL ISOLATION
SUICIDAL THOUGHTS
WORRIED
WORTHLESS

SLEEP

I sleep about 8 hours a night and awake feeling restedI sleep about 8 hours a night and wake feeling tiredI have trouble falling asleepI have trouble staying asleep with middle of the night awakeningsI awaken early in the morning around 3 AMI have restless legsI have nightmares

HOW WOULD YOU RATE YOUR HEALTH?

	1	2	3	4	5

1 is Worst, 5 is Best

HEALTH PROVIDER THAT YOU SEE REGULARLY

First NameLast Name
Would you like to provide consent to share information about your care with your provider?

YESNO
NAME OF YOUR THERAPIST

First NameLast Name
Would you like to provide consent to share information about your care with your therapist ?

YESNO
Would you like to provide consent to share information about your care with another person? (PARENT, SPOUSE, RELATIVE, OR OTHER)

First NameLast Name
Support Groups that you attend
ALLERGIES
SOCIO ECONOMIC HISTORY
LIVING SITUATION

Housing AdequateHomelessHousing overcrowdedDependent on others for housingHousing dangerous/deterioratingLiving companions dysfunctional
SOCIAL SUPPORT SYSTEM

Supportive NetworkFew friendsSubstance use based frinedsNo friendsDistance from family of origin
EMPLOYMENT

Employed and satisfiedEmployed but dissatisfiedUnemployed looking for a jobUnemployed not lookingCoworker conflictsSupervisor ConflictsUnstable work historyDisabledCurrently on Disability AssistanceLooking to obtain disabilityCurrently on Short Term Disability
LEGAL HISTORY

No legal problemsNow on parole/probationArrest(s) not substance relatedArrest(s) substance relatedCourt ordered TreatmentRestraining order in placeJail
MILITARY HISTORY

Never in militaryServed in miliary no incidentServed in military with incidentCurrently serving in militaryHonorable dischargeOther type of discharge
RELATIONSHIP HISTORY

MarriedDivorcedSingleWidowedIn a relationshipChildren living at homeChildren living elsewhere

CHILDREN

	NAME	AGE	STEP CHILD	ADOPTED
SON
SON
SON
SON
DAUGHTER
DAUGHTER
DAUGHTER
DAUGHTER

DEVELOPMENTAL HISTORY
PROBLEMS DURING MOTHER'S PREGNACY

NoneHigh blood pressureKidney infectionGerman MeaslesEmotional StressBleedingAlcohol UseDrug UseNicotine Use
BIRTH

Normal DeliveryDifficult DeliveryCesarean deliveryComplicationsPremature
PROBLEMS IN CHILDHOOD

FEEDING PROBLEMSSLEEP PROBLEMSTOILET TRAINING PROBLEMS
BIRTH WEIGHT
DELAYED DEVELOPMENT MILESTONES

SittingSpeaking wordsDressing SelfRiding a bicycleRolling overSpeaking sentencesEngaging peersStandingControlling bladderTolerated separationWalkingControlling BowelsPlaying cooperativelyFeeding selfSleeping aloneRiding Tricycle

CHILDHOOD HEALTH

	HAD	AGE
Chicken Pox
Scarlet fever
Responsiveness
Phneumonia
Asthma
German Measles
Lead Poisoning
TB
Measles
Mumps
Rheumatic Fever
Whopping Cough
Polio
Ear Infections

Social Interaction

Normal social interactionDominates othersIsolates selfVery shyAlienates selfAssociates with acting out peersBulliedInappropriate sex playOther
EMOTIONAL/BEHAVIORAL PROBLEMS

Drug UseFire SettingRepeats words of othersNone verbalBizarre behaviorDistrustfulPoor ConcentrationAlcohol AbuseHyperactiveNot trustworthySelf injurious threatsExtreme worrierOften sadChronic lyingAnimal crueltyHostile/Angry moodFrequently tearfulSelf injurious actsBreaks thingsStealingAssaults othersIndecisiveFrequently daydreamsImpulsiveViolent temperDisobedientImmatureLack of attachmentEasily distractedOther
Intellectual/Academic function

Normal intelligenceHigh intelligenceLeaning disabilityAuthority conflictsUnder achievingMild intellectual impairmentModerate intellectual impairmentSevere intellectural impairmentNeeded speech therapyNeeded physical therappyNeeded occupational therapyHas IEPSpecial Education

FAMILY HISTORY

	PRESENT ENTIRE CHILDHOOD	PRESENT PART OF CHILDHOOD	NOT PRESENT AT ALL	PARENT'S CURRENT MARITAL STATUS?
BIOLOGICAL MOTHER
BIOLOGICAL FATHER
ADOPTIVE MOTHER
ADOPTIVE FATHER
STEP MOTHER
STEP FATHER
BROTHERS
SISTERS
OTHER

CHILDHOOD FAMILY EXPERIENCE

Outstanding home environmentNormal home environmentChaotic home enviornmentNeglectedWitnessed physical/verbal/sexual abuse towards othersExperienced physical/verbal/sexual abuse from others
Age of emancipation from home

PSYCHIATRIC HISTORY

	YES	NO	Dates Treated	REASON
Have you ever been treated for a psychiatric illness
Have you ever attempted to kill yourself
Have you ever attempted to harm someone else
Have you ever been hospitalized for a psychiatric condition
Have you ever been treated for substance abuse
Any history of Trauma
Have you ever engaged in self harming behavior
Have you ever been bulimic or anorexic
Have you had rTMS treatment?
Have you had ECT treatment?
Have you had Ketamine treatments?

FAMILY MENTAL HEALTH HISTORY
ADOPTED?

YESNO
SUICIDE

MotherFatherSisterBrotherMom's MomMon's DadDad's MomDad's FatherOther RelativeOther
DEPRESSION

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
ANXIETY

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
BIPOLAR

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
SCHIZOPHRENIA

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
ALCOHOLISM/DRUG USE

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
LEARNING DISABILITY/ADHD OR ADD

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
PANIC ATTACKS

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
OBSESSIVE COMPULSIVE DISORDER

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
SUICIDE ATTEMPTS

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther
PSYCHIATRIC HOSPITALIZATION

MotherFatherSisterBrotherMom's MomMom's DadDad's MomDad's FatherOther RelativeOther

Medications you are taking or have taken in the past

	CURRENTLY TAKING	TAKEN IN THE PAST	DID IT HELP?	SIDE EFFECTS	APPROXIMATE DATE TAKEN	DOSEAGE
Escitalopram (Lexapro)
Citalopram (Celexa)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Levomilnacipran (Fetzima)
Milnacipran (Savella)
Venlafaxine (Effexor)
Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Nefazodone
Trazodone
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
Amitriptyline (Elavil)
Amoxapine (Asendin)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortiptyline (Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
Phenelzine (Nardil)
Selegiline (Emsam)
Tranylcypromine (Parnate)
Carbamazepine (Tegretol®)
Gabapentin (Neurontin®,
Lamotrigine (Lamictal®)
Lithium (Lithobid®, Eskalith®)
Oxcarbazepine (Trileptal®)
Pregabalin (Lyrica®
Topiramate (Topamax®)
Valproate (Depakote®, Depakene®
Aripiprazole (Abilify®)
Asenapine (Saphris®
Brexpiprazole (Rexulti®)
Cariprazine (Vraylar®)
Clozapine (Clozaril®)
loperidone (Fanapt®)
Lurasidone (Latuda®)
Olanzapine (Zyprexa®)
Paliperidone (Invega®)
Quetiapine (Seroquel®)
Risperidone (Risperdal®)
Ziprasidone (Geodon®)
Chlorpromazine (Largactil®, Thorazine®)
Fluphenazine (Prolixin®)
Haloperidol (Haldol®
Loxapine (Loxitane®)
Perphenazine (Trilafon®)
Perphenazine (Trilafon®)
Promethazine (Phenegran®)
Thioridazine (Mellaril®)
Thiothixene (Navane®
Trifluoperazine (Stelazine®
Alprazolam (Xanax®)
Buspirone (Buspar®)
Chlordiazepoxide (Librium®)
Clonazepam (Klonopin®)
Clorazepate (Tranxene®)
Diazepam (Valium®)
Hydroxyzine (Vistaril®)
Hydroxyzine (Vistaril®)
Oxazepam (Serax®)
Propranolol (Inderal®)
Temazepam (Restoril®)
Amphetamine-Dextroamphetamine
(Adderall®, Evekeo®, Dyanavel®, Adzenys®)
Dexmethylphenidate (Focalin®)
Dextroamphetamine (Dexedrine®, Procentra®, Zenzedi®)
Lisdexamfetamine (Vyvanse®
Methamphetamine (Desoxyn®)
Methylphenidate (Ritalin®, Concerta®, Daytrana®, Metadate®)
Armodafinil (Nuvigil®)
Atomoxetine (Strattera®)
Clonidine (Kapvay®
Guanfacine (Intuniv®)
Modafinil (Provigil®
Eszopiclone (Lunesta®)
Ramelteon (Rozerem®)
Suvorexant (Belsomra®)
Zaleplon (Sonata®)
Zolpidem (Ambien®)

PERSONAL AND FAMILY MEDICAL HISTORY

	YOU	FAMILY MEMBEB	WHO?	CURRENT	PAST
Allergy (hay fever)
Anemia
Anemia
Bladder/kidney problems
Blood Clot
Blood Transfusion
Cancer Breast
Cancer Colon
Cancer Prostate
Cancer Ovarian
Cancer Thyroid
Cataracts
Colon polyp
Coronary Artery Disease
Diabetes
Diverticulitis
Emphysema (COPD)
Gallbladder Disease
Heart attack
Hepatitis Type A, B, C
High Blood Pressure
High Cholesterol
Hip Fracture
Irritable Bowel Syndrome
Kidney Disease/Failure
Kidney Stones
Liver Disease
Migraine Headaches
Osteoporosis
Pneumonia
Prostate enlargement
Seizure/Epilepsy
Traumatic Brain Injury with coma
Traumatic Brain Injury without coma
Skin Conditions
Sleep Apnea
Stomach Ulcer
Stroke
Thyroid nodule
Thyroid hypothyroidism
Thyroid hyperthyroidism

SUBSTANCE ABUSE STATUS

No history of abuseActive abuseEarly full remissionEarly partial remissionSustained full remissionSustained partial remission
TREATMENT HISTORY

Out patientIn patient12 Step ProgramStopped on ownOther

SUBSTANCE USED

	EVER USED	LAST USAGE	CURRENTLY USED	FREQUENCY	AMOUNT	FIRST AGE USED
ALCOHOL
Ampetamines/Speed
Barbituates
Caffeine
Cocaine
Crack Cocaine
Ectasy
Hallucinogens (LSD)
Heroin
Inhalents
Marijuana
Methadone
Methamphetamine
Pain killers
Nicotine/Tobacco/Vape
PCP
Tranquilizers

CURRENT MEDICATIONS

Please list all of the medications that you take on a daily basis
CURRENT MEDICATION 1
CURRENT MEDICATION 2
CURRENT MEDICATION 3
CURRENT MEDICATION 4
CURRENT MEDICATION 5
CURRENT MEDICATION 6
CURRENT MEDICATION 7
CONSENT FOR TREATMENT

MARYANN RYAN, NPP OR MARY F. SWITALA, NPP
Name of provider*
Date

MonthDayYear
Date
INITIAL EVALATION & SESSIONS

We generally conduct a thorough psychiatric evaluation during the initial session – which is typically scheduled for 60 minutes. This assessment focuses on determining the best treatment plan possible and is specific to each individual patient. It is extremely important for this initial assessment to be as comprehensive as possible. Therefore, please bring completed patient forms to this appointment and make sure to provide information about previous providers, past psychiatric treatment, and medication trials. In some situations, extra sessions are needed to complete an appropriate evaluation. Additionally, collateral information (i.e., school reports, family reports, etc are often necessary for children and adolescents – and helpful for adult patients as well. These issues will be discussed during the initial session. Please remember that a comprehensive assessment is necessary as it allows us to provide the best possible care.
PRACTICE STATUS

There are other independent providers who sublease office space within the suite. While we share space and often provide collaborative care, each provider is responsible for providing care up to professional standards. All records are stored using an industry leading electronic health record called Practice Fusion. The office manager also may, at times, have access to your record. Please note that it is our policy to always protect this information in accordance with all legal and ethical standards. Additionally, your provider within a network of other professional colleagues (i.e., primary care doctors, other specialty physicians, psychologists, social workers, therapists, nutritionists, etc that we use as referrals for multidisciplinary care. If a referral is necessary, this will be discussed in session and your provider will work to collaborate with these professionals and coordinate your care. Please note, however, that although we attempt to identify top quality professionals with very high standards of care, we cannot be responsible for the services/treatment that they provide. It is always your responsibility to determine if a professional referral is acceptable, and alternative options will be considered.
MEDICATION MANAGEMENT

Psychiatric medications can be used in conjunction with psychotherapy to treat many conditions. It is important to find the best combination of medications and therapy for each individual case. Your nurse practitioner of psychiatry can provide an integrated approach as a nurse practitioner of psychiatry is trained to administer both psychiatric medications and psychotherapy. However, in almost all situations, it will be appropriate to consider only managing your psychiatric medications and sharing the psychotherapy with an alternative provider. We can help find a provider for you in the community. In situations that warrant the use of medications, it is imperative for you to understand the target symptoms and likely outcomes. Additionally, since all medications have the potential for side effects, your nurse practitioner will always discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you.
REFILLS

We make every effort to see you before you need a refill. We need atleast 2 days to refill a medication and reserve the right to refuse to renew a medication if in the provider's opinion, the patient needs to be evaluated before a refill is given. ALL PATIENTS THAT ARE PRESCRIBED A CONTROLLED SUBSTANCE MUST BE SEEN ON A MONTHLY BASIS. Patients that are not seen for more than 3 months are considered to no longer be under the care of the provider. In such cases, the provider will need to see the individual as a new patient after that time.
BILLING AND PAYMENTS

I understand that I am expected to pay my copay for each session at the beginning of each appointment. Alternative payment plans must be discussed with and agreed to by your provider.I understand that payment for ‘other professional services’ such as Legal documentation, Disability, other issues will be billed to the patient at $200 per hour. I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of benefits to the party who accepts assignment. I authorize payment of medical benefits to Maryann Ryan, NPP for services.
CANCELLATIONS AND NO-SHOW POLICY

Once your appointment is scheduled, you will be expected to pay the full professional fee unless you provide at least 48 business hours advance notice of cancellation. Both telephone and email are acceptable ways to alert us of a cancellation. Please remember that business hours are considered weekdays from Monday through Friday and exclude all standard holidays. Also, insurance companies generally do not reimburse for missed sessions or those cancelled too late
CONTACTING YOUR PROVIDER

We always attempt to be accessible for all urgent issues. If your provider is not immediately available by office telephone (845-545-5444), please leave a voice message and we will return your call as soon as possible. Calls are generally returned within one business day. Please always leave a phone number where you can be best reached. If your call is an emergency, please contact 911 immediately instead of calling the office. Emergency psychiatric services are provided by all hospitals through their emergency rooms and do not require appointments. Emergency room physicians can contact your provider at any time so please provide them with his/her contact information. When your provider is unavailable for extended periods of time (i.e., vacation, conferences, etc, a trusted colleague will provide coverage and contact information will be provided on the office voicemail. Please also note that email OR texts should never be used for urgent or emergency issues. This is not a confidential means of communication and we cannot ensure that email or text messages will be received or responded to in a timely fashion
PROFESSIONAL RECORDS

Both law and professional standards protect mental health records. Although you are entitled to review a copy, these records can be misinterpreted given their professional nature. In rare cases when it is deemed potentially damaging to provide you with the full records directly, we can review them together and/or treatment summaries can be provided.
CONSENT FOR USE OF AI SCRIBE DURING ENCOUNTERS

We are using new technology to help provide the best care possible for you. We are using an AI tool assists us during patient encounters by generating clinical notes based on our conversations. This allows us to focu more on you, the patient , and less on computer documentation. The AI tool does not interact with you directly. It merely listens to the conversation and creates a summary. The AI tool listens to the conversation during the visit and geneates a written summary or "note" based on that conversation. This note is then reviewed and approved by your practiitioner. Your privacy is our utmost priority. The AI tool adheres strictly to HIPPA compliance gudelines to ensure that your data is secured and protected. Your participation is completely voluntary.
CONSENT TO OBTAIN PRESCRIPTION HISTORY

Patient gives consent to retrieve prescription history from Sure Scripts when request is triggered. The purpose of this information is to reconcile all medications as part of our standard of care.
CONSENT TO RECEIVED APPOINTMENT REMINDERS AND MESSAGING

Patient consents to receive appointment reminds and messaging through HIPPA compliant scheduling APP.
CONFIDENTIALITY

Confidentiality is a cornerstone of mental health treatment and is protected by the law. Aside from emergency situations, information can only be released about your care with your written permission. If insurance reimbursement is pursued, insurance companies also often require information about diagnosis, treatment, and other important information (as described above) as a condition of your insurance coverage. Several exceptions to confidentiality do exist that actually require disclosure by law: (1) danger to self – if there is threat to harm yourself, we are required to seek hospitalization for the client, or to contact family members or others who can help provide protection; (2) danger to others – if there is threat of serious bodily harm to others, we are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization; (3) grave disability – if due to mental illness, you are unable to meet your basic needs, such as clothing, food, and shelter, we may have to disclose information in order to access services to provide for your basic needs; (4) suspicion of child, elder, or dependent abuse – if there is an indication of abuse to a child, an elderly person, or a disabled person, even if it is about a party other than yourself, we must file a report with the appropriate state right to agency; (5) certain judicial proceedings – if you are involved in judicial proceedings, you have the right to prevent us from providing any information about your treatment. However, in some circumstances in which your emotional condition is an important element, a judge may require testimony through a court order. Although these situations can be rare, we will make every effort to discuss the proceedingswith you accordingly. We also reserve the right to consult with other professionals when appropriate. In these circumstances, your identity will not be revealed and only important clinical information will be discussed. Please note that such consultants are also legally bound to keep this information confidential.
ELECTRONIC MAIL (EMAIL) OR TEXTS

Always be aware that email or text messages are not a confidential means of communication. We cannot guarantee that email messages or text messages will be received or responded to in a timely fashion. As such, email or texts messages is not an appropriate way to communicate confidential or urgent information.
LEGAL TESTIMONY

Legal matters requiring the testimony of a mental health professional can arise. This, however, can be damaging to the relationship between a patient and his/her provider. As such, we generally recommend that you hire an independent forensic mental health professional for such services.
Your signature below indicates that you have read the Treatment Consent Form, which contains information on psychiatric services, sessions, professional fees, cancellation and no-show policies, billing and payments, insurance reimbursement, contacting providers, professional records, confidentiality, and practice status, and you agree to abide by its terms during our professional relationship.*

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Psychiatric Nurse Practitoners of Warick

COMPREHENSIVE NEW PATIENT HEALTH HISTORY QUESTIONAIRE

CURRENT MEDICATIONS

CONSENT FOR TREATMENT

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