New Patient Evaluation Form
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: YesNo
Too "up" or too elevated: YesNoBoth
Anxiety, worry, nervousness, panic: YesNoNot sure
Sleep problems: insomnia or not enough sleep: YesNo
Too much sleep: YesNoBoth
Irritability or losing your temper, anger: YesNoNot sure
Problems with memory, concentration, mental clarity, confusion: YesNoNot sure
Being affected by previous traumatic experiences: YesNoNot sure
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: YesNoNot sure
Repetitive, hard to control behaviors (such as counting, checking, ordering) OR repetitive, hard to control thoughts: YesNoNot sure
Problems with food or eating: YesNo
Problems with your appearance or body image: YesNoNot sure
Feeling uncomfortable with your childhood assigned gender: YesNoNot sure
Problems with gambling: YesNoNot sure
Taking actions that cause pain or injury to your body without wanting to die of it: YesNoNot sure
Thoughts of wanting to die or suicidal thoughts: YesNoNot sure
Feeling detached or distant from your body, your surroundings, or other people: YesNoNot sure
Internet/social media/gaming that you can't seem to control: YesNoNot sure
Previous Mental Health Treatments:
Outpatient psychiatric treatment, counseling/psychotherapy, prior to CFD: YesNo
What was helpful?
What was unhelpful?
Hospitalizations for mental health reasons: YesNo
Approximately how many?
As best as you're able to say, when were they, or how old were you?
Any suicide attempts? YesNo
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? YesNo
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? YesNo
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):
Opioid pills or heroin:
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? YesNo
Please briefly describe your nutrition or eating habits:
Please CHECK any of these you have had within the last month:
HEENT: headaches dry mouth blurred vision grinding/clenching teeth snoring
Cardiac: heart palpitations racing heart chest pain
Respiratory: shortness of breath coughing wheezing
Stomach/bowel: nausea vomiting diarrhea constipation abdominal pain
Urinary: leakage hard to start stream burning frequent urge excessive urination
Musculoskeletal: joint pain muscle pain
Skin: rash itching excessive sweating acne hair loss excessive hair growth
Neuro: tremor/shakiness dizziness unsteadiness falls numbness/tingling slurred speech movements not done on purpose restlessness/restless legs
Endocrine: change in sexual function change in menstrual cycle feeling too hot or too cold excessive thirst breast enlargement breast discharge
Blood/heme: easy bruising unusual bleeding
General: fever change in weight change in appetite
What do you hope for your future?
Is there anything else you would like me to know right away?
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Patient Evaluation Form
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