µ o W Ç Z ] ] / v l & } u€¦ · Ambien (zolpidem) Lunesta (Eszopiclone) Unisom (Doxylamine) Benadryl (Diphenhydramine) Rozerem (Ramelteon) Sonata (Zaleplon) REVISED - P E M hZZ

!Řdzƭǘ tǎȅŎƘƛŀǘNJƛŎ LƴǘŀƪŜ CƻNJƳ D9b9w![ LbChwa!¢Lhb tŀǘƛŜƴǘ bŀƳŜΥ________________________________________ 5ŀǘŜ ƻŦ .ƛNJǘƘΥ_________________

Please describe the reason for visit and/or current concerns:

wL{Y !{{9{{a9b¢ Yes No Have you ever attempted suicide?

Have you ever harmed yourself by cutting, burning, etc.? Yes No

Have you recently engaged in risk-taking behavior? ό/ƘŜŎƪ ŀƭƭ ǘƘŀǘ ŀLJLJƭȅύ Alcohol/Drug use Gang involvement Unprotected Sex Drug dealing Shoplifting Trading sex for money, drugs, or possessions Reckless driving Carrying/using a weapon Other: ___________________________________________________________________________

Yes No Yes No Yes No

Do you feel that you live in a safe place? Are there guns in your home? If yes, are the guns locked up? Have you ever witnessed violence in the home?

Yes No

[9D![ Lb±h[±9a9b¢ Yes No

No Have you ever been on probation? Have you had any other involvement with the legal system? If yes to any of the above, please explain:

a9b¢![ I9![¢I IL{¢hw¸ tƭŜŀǎŜ ŎƘŜŎƪ ŀƭƭ ŎdzNJNJŜƴǘ ŀƴŘ LJNJŜǾƛƻdzǎ ƳŜƴǘŀƭ ƘŜŀƭǘƘ ŎŀNJŜ tNJƻǾƛŘŜ ŘŜǘŀƛƭǎ όŜΦƎΦ ǿƘŜNJŜΣ ƴdzƳōŜNJ ƻŦ ǘƛƳŜǎΣ LJNJƻǾƛŘŜNJ ƻNJ ǘƘŜNJŀLJƛǎǘ ƴŀƳŜΣ ŎŀǎŜǿƻNJƪŜNJΣ ŜǘŎΦύ Partial Hospitalization Detail: _____________________________________________ Intensive Outpatient Detail: _____________________________________________ Residential Treatment Detail: _____________________________________________ Day Treatment Detail: _____________________________________________ Psychiatric Care Detail: _____________________________________________ Outpatient Therapy Detail: _____________________________________________ Substance Abuse Treatment Detail: _____________________________________________ Detox Detail: _____________________________________________ Case Management Detail: _____________________________________________ In-home skills/family therapy Detail: _____________________________________________ Other:

REVISED - August 2019 Page 1 of 5

Yes

PAST PSYCHOTROPIC MEDICATION HISTORY Antidepressants Prozac (Fluoxetine) Zoloft (Sertraline) Luvox (Fluvoxamine) Paxil (Paroxetine) Celexa (Citalopram) Lexapro (Escitalopram) Effexor (Venlafaxine) Pristiq (Desvenlafaxine) Cymbalta (Duloxetine) Wellbutrin (Bupropion) Desyrel (Trazodone) Remeron (Mirtazapine) Serzone (Nefazodone) Anafranil (Clomipramine) Pamelor (Nortriptyline) Viibryd (Vilazodone) Elavil (Amitriptyline) Tofranil (imipramine) Fetzima (levomilnacipran) Trintellix (vortioxetine) Other: Mood Stabilizers Tegretol (Carbamazepine) Lithium Depakote (Valproate) Lamictal (Lamotrigine) Trileptal (Oxcarbazepine) Other:__________________ Neuroleptics / Antipsychotics Risperdal (Risperidone) Seroquel (Quetiapine) Zyprexa (Olanzepine) Geodon (Ziprasidone) Abilify (Ariprprazole) Clozaril (Clozapine) Haldol (Haloperidol) Prolizin (Fluphenazine

Vraylar (Cariprazine) Invega (Paliperidone) Latuda (lurasidone) Rexulti (brexpiprazole) Saphris (asenapine) Other:_________________

Anti-Hypertensives / Anti-Anxiety Catapres (Clonidine Tenex (Guanfacine) Intuniv (Guanfacine XR) Inderal (Propanolol) Atenolol (Tenormin) Other: _________________

Benzodiazepines / Sedatives Xanax (Alprazolam) Ativan (Lorazepam) Restoril (Temazepam) Klonopin (Clonazepam) Valium (Diazepam) Ambien (Zolpidem) Buspar (Buspirone) Other: __________________

Stimulants Adderall (amphetamine) Vyvanse (Dexamphetamine) Concerta (Methylphenidate) Ritalin LA (Methylphenidate) Daytrana (Methylphenidate) Metadate (Methylphenidate) Focalin (Dexmethylphenidate) Strattera (Atomoxetine) Other: __________________

Sleep Aids Melatonin Desyrel (Trazodone) Remeron (Mirtazapine) Ambien (zolpidem) Lunesta (Eszopiclone) Unisom (Doxylamine) Benadryl (Diphenhydramine) Rozerem (Ramelteon) Sonata (Zaleplon)

REVISED - August 2019 Page 2 of 5

/¦ww9b¢ a95L/![ /hb/9wb{ IŜŀŘ DŀǎǘNJƻƛƴǘŜǎǘƛƴŀƭ /ƻƴǎǘƛǘdzǘƛƻƴŀƭ

Concussion Heartburn/reflux Weight loss Head injury Nausea/vomiting Fatigue Headaches Constipation Fever Migraines Change in bowel movements Other: _____________ Traumatic Brain Injury Jaundice Other: _____________ Abdominal Pain bŜdzNJƻƭƻƎƛŎŀƭ

Black or bloody bowel movement Loss of strength 9ȅŜǎ Other: _____________ Numbness

Needs glasses/contacts Headaches Eye pain DŜƴƛǘƻdzNJƛƴŀNJȅ Tremors Double vision Burning/frequency Memory Loss Decreased vision Bedwetting Tourette’s Syndrome Other: _____________ Blood in urine Seizures

Erectile dysfunction Other: _____________ 9ŀNJǎΣ bƻǎŜΣ ¢ƘNJƻŀǘ Abnormal discharge

Difficulty hearing Bladder leakage 9ƴŘƻŎNJƛƴƻƭƻƎƛŎŀƭ Ringing in ears Menstruation Unexplained weight loss Vertigo Other: _____________ Weight gain Difficulty swallowing Hot/cold intolerance Pain adzǎŎdzƭƻǎƪŜƭŜǘŀƭ Diabetes Other: _____________ Hypothyroidism

Other: _____________ /ŀNJŘƛƻǾŀǎŎdzƭŀNJ

Murmur /ƘNJƻƴƛŎ LƭƭƴŜǎǎ Chest pain Asthma Palpitations Diabetes Dizziness {ƪƛƴ Other: _____________ Fainting Spells Shortness of breath {ŜƴǎƻNJȅ ŎƻƴŎŜNJƴǎ Difficulty lying flat Sound/noises Swelling Ankles Touch/tactile Other: _____________ Oral/Textures

Joint pain/swelling Stiffness Muscle pain Back pain Other: _____________

Hair loss Rash/hives Lesions/sores Itching/burning Easy bruising Other: _____________ Clothing/Tactile

wŜǎLJƛNJŀǘƻNJȅ Other: _____________ Cough illness Pain Shortness of breath Use of inhaler use of oxygen Other: _____________

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REVISED - August 2019 Page 4 of 5

SUBSTANCE USE (PAST AND CURRENT)- PLEASE LIST AMOUNT, FREQUENCY, AND PRODUCT

Caffeine _____________________________________________________________________ Nicotine _____________________________________________________________________ Alcohol _____________________________________________________________________ Marijuana _____________________________________________________________________CBD _____________________________________________________________________

Other Drug Use _________________________________________________________________

Have you been in treatment for substance abuse?

YesNoIf yes list date, location, and completed or not completed: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Social History:

Relationship Status:_______________________________________________________

Who do you live with?_____________________________________________________

Who is most supportive to you? _____________________________________________

Religious beliefs: _________________________________________________________

C!aL[¸ a9b¢![ I9![¢I IL{¢hw¸ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________

Suicide attempt Suicide completed Schizophrenia Bipolar Disorder Depression Anxiety ADHD Autism Spectrum Disorder Alcoholism Drug addiction Other addictive behaviors Other: ______________________________

Who:____________________________________

REVISED - August 2019 Page 5 of 5

95¦/!¢Lhb IL{¢hw¸ Highest Level of Education Completed _________________________________ School: ___________________AaaaAny Academic Difficulties______________________________________________________________________

9at[h¸a9b¢

Not employed What is your employment status? όŎƘŜŎƪ ƻƴŜύ Employed full-time Employed part-time Not employed and NOT seeking employmentand seeking employment

LŦ ŜƳLJƭƻȅŜŘΣ ǿƘŀǘ ƛǎ ȅƻdzNJ ƻŎŎdzLJŀǘƛƻƴΚ _______________________________________________