Patient History Form | NV Mental Health

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?