New Patient Evaluation Form


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

New Patient Evaluation Form

Name:      Date:

What are you seeking help with?

What is the most stressful thing in your life right now?

Are the following causing you difficulty or distress? (Feel free to skip questions, if you wish.)

Mood problems: Too low, down, or depressed:

Too "up" or too elevated:

Anxiety, worry, nervousness, panic:

Sleep problems: insomnia or not enough sleep:

Too much sleep:

Irritability or losing your temper, anger:

Problems with memory, concentration, mental clarity, confusion:

Being affected by previous traumatic experiences:

Odd or unusual experiences or beliefs that others don't often share, such as hearing things that others do not, or feeling others can read your thoughts:

Repetitive, hard to control behaviors (such as counting, checking, ordering) OR repetitive, hard to control thoughts:

Problems with food or eating:

Problems with your appearance or body image:

Feeling uncomfortable with your childhood assigned gender:

Problems with gambling:

Taking actions that cause pain or injury to your body without wanting to die of it:

Thoughts of wanting to die or suicidal thoughts:

Feeling detached or distant from your body, your surroundings, or other people:

Internet/social media/gaming that you can't seem to control:

 

Previous Mental Health Treatments:

Outpatient psychiatric treatment, counseling/psychotherapy, prior to CFD:

Where:

When:

What was helpful?

What was unhelpful?

Hospitalizations for mental health reasons:

Approximately how many?

As best as you're able to say, when were they, or how old were you?

Any suicide attempts?

How many?

When were they or how old were you?

Mental health diagnoses you have previously been given, if you're able to say:

Medications you have tried before for your mental health symptoms, as best as you can say (please include name, dose, approx. when taken, took for how long, and effects/side effects):

Other treatments such as light therapy, TMS, ECT?

Current and past medical conditions:

Please note surgeries you have had:

Allergies to medications:

Method of birth control, if applicable:

Last menstrual period, if applicable:

Planning pregnancy?

Family mental health history: mood, anxiety, psychosis, ADHD, OCD, developmental, suicide or suicide attempts, hospitalizations:

Family medical history:

Substance use history: 

Please describe your personal use of (please include current amount per week/month and past use):

     Alcohol:

    Tobacco:

     Cannabis:

     Meth, cocaine:

     Opioid pills or heroin:

     Caffeine:

     Prescriptions (Adderall or a "benzo"?):

     Other (ie. Kratom):

Are you worried about your own use of substances?

Have others expressed worry or disapproval about it?

Please note previous or current attendance at treatment facilities or meetings such as 12 step:

Do you own or have access to firearms or other weapons?

Please briefly describe your nutrition or eating habits:

Please CHECK any of these you have had within the last month:

     HEENT:

     Cardiac:

     Respiratory:

     Stomach/bowel:

     Urinary:

     Musculoskeletal:

     Skin:

     Neuro:

     Endocrine:

     Blood/heme:

     General:

What do you hope for your future?

Is there anything else you would like me to know right away?

Leave this empty:

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Document name: New Patient Evaluation Form
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November 22, 2021 10:56 am PSTNew Patient Evaluation Form Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
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