COMPREHENSIVE NEW PATIENT HEALTH HISTORY QUESTIONAIRE

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 *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
Phone Number

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

HOW WOULD YOU RATE YOUR HEALTH?

	1	2	3	4	5

1 is Worst, 5 is Best

Main reason for your visit?
HEALTH PROVIDER THAT YOU SEE REGULARLY

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

YES NO
NAME OF YOUR THERAPIST

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

YES NO
Would you like to provide consent to share information about your care with another person? (PARENT, SPOUSE, RELATIVE, OR OTHER)

First Name Last Name
Support Groups that you attend
ALLERGIES

PSYCHIATRIC HISTORY

	No	Yes
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

FAMILY MENTAL HEALTH HISTORY
SUICIDE

Mother Father Sister Brother Mom's Mom Mon's Dad Dad's Mom Dad's Father Other Relative
DEPRESSION

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
ANXIETY

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
BIPOLAR

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
SCHIZOPHRENIA

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
ALCOHOLISM/DRUG USE

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
LEARNING DISABILITY

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
PANIC ATTACKS

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative
OBSESSIVE COMPULSIVE DISORDER

Mother Father Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Father Other Relative

Medications you are taking or have taken in the past

	Currently taking	Taken in the past	Side effects?
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 MEDICAL HISTORY

	CURRENT	HISTORY OF
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

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

Month Day Year
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.
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. *

First Name Last Name
Signature *

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GUARDIAN Signature

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Credit Card on File

We require a credit card on file for Copays, Deductible amounts from insurance and Self Pay
Cardholder Name (as shown on card)

First Name Last Name
Last four numbers on Credit Card
Card CVV
Expiration
Zip code associated with credit card
I authorize the below selected person to charge my credit cared for the agreed upon services. I understand that my information will be saved to a file for future transactions on my account.
x Signature

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COMPREHENSIVE NEW PATIENT HEALTH HISTORY QUESTIONAIRE

CURRENT MEDICATIONS

CONSENT FOR TREATMENT

Credit Card on File