New patient intake Sh | Brain Health USA

Name *

First

Last

Date Of Birth *

Phone number *

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload Copy of ID (Driver License/Passport)

Click or drag a file to this area to upload.

Insurance Name *

Insurance id number

Please upload Front and back of the Insurance card

Click or drag files to this area to upload.

You can upload up to 2 files.

Please upload Front and back of the pharmacy card

Click or drag files to this area to upload.

You can upload up to 2 files.

Social security number *

Height

5:11

Weight

190

Intake Questions

Please state if you have any problems with the following systems

Eyes
Ears
Lungs
Heart
Urinary/genitalia
Skin
Neurological
Thyroid
Blood
NO, I have not been Diagnosed with any chronic diseases in any of my systems

Please explain

Blood Pressure

Low
Normal
High

Medical History

Main Reason for seeking mental health services?

Evaluation/Consultation
Medication Management

Please elaborate in order to help assist you better.

Previous Diagnosis? *

None
Depression
Anxiety
ADHD/ADD
Bipolar disorder
Schizophrenia
PTSD
Eating disorder
Insomnia
Autism
Substance abuse

Are you currently taking medication? *

Please list names and dosages of your current medications?

Were you previously taking any medication.

Please list names and dosages of your Previous medications

Have you ever been hospitalized for any psychiatric reasons?

please list dates/ reasons for past psychiatric hospitalizations.

Does any of your immediate family have a history of psychiatric diagnoses that you know of?

please list their diagnosis and relationship to you.

Example: Mother: Depression or depression runs is the family

Any Medication Allergies?

Please list all the medication you are allergic to.

Any Past Surgeries?

Please list the surgery and year.

Example:Gallbladder removal in 2019

Do you have any pending or past legal problems?

Please state the problem and year.

Example: past domestic violence with my previous girlfriend in 2019.

Do you have any eating disorder?

please state Anorexia/Bulimia/binge eating or others: and if it is Ongoing/ in the past.

Example: past domestic violence with my previous girlfriend in 2019.

Have you ever had a DUI?

how many times with dates.

Example: twice in 2011 and 2019

Have you ever had any head injuries or seizures?

Have you ever had any physical, sexual or mental abuse as a child or as an adult?

Please elaborate in order to help assist you better.

Example: Physical/sexual/Mental as child/Adult/Both, and further elaboration: (Optional)

Social History

Do you use drugs including Cannabis/Weed/Marijuana? *

what type of Drugs and on average how many times?

Example: Weed 3 times a day/week

Do you smoke Tobacco or Vape?

Do you drink alcohol? *

on average how many times?

Example: 3 times a week/month

Have you ever been to a drug/alcohol rehab?

Please, provide us with dates.

Example: 3 times a week/month

Education?

11th grade
Highschool
Some college
AA degree
Bachelor’s degree
Master’s degree
PHD

Currently working?

Family History

Marital status?

Married
Single
Other
in a relationship
Engaged
Divorced
Widow

Number of children?

Number of siblings?

How would you describe your relationship with your family?

Your current living situation?

Example: I live with my wife and children

On average how many hours do you sleep per day?

Example: 7 to 8 hours a day

Appetite?

Poor
Normal
Big
inconsistent

What's your treatment goal?

Example: To be able to cope with my stress and figure best treatment plan for my ADHD.

Do you agree to receive text messages from Brain Health USA? *