Assessment Forms | Oden Psychiatry in Atlanta

PRE-INTAKE DEMOGRAPHICS AND SELF-ASSESSMENT

First Name

Last Name

Age

Date of Birth

Location of Birthplace

Preferred Pronouns

Address:

Telephone *

Email *

Primary Care Physician:

Please provide the name and location of your primary care physician or type in N/A if you do not have one.

Therapist:

Please provide your Therapist details or type in N/A if you do not have one.

Other potentially helpful contacts:

Insurance:

Name of person to call in an emergency

Relationship to emergency contact above

Address of emergency contact

Summarize briefly why you are seeking treatment at this time:

Psychiatric History

Have you ever had psychiatric treatment? List treaters:

Prior psychiatric diagnoses:

Has there been any psychiatric hospitalizations?

Medications

Current medications and dosages, including over-the-counter medications, herbal and/or vitamin supplements:

Past medications:

Medical History

Any allergies or adverse reactions to medications:

Past medical problems:

Active medical problems:

Family History

Is there any family history of mental health or substance abuse problems? Please also indicate any negative or positive responses to psychiatric medications among your family, if known. If adopted, please summarize what you know about your family of origin.

Additional Information

List parents, siblings:

Who do you currently live with (if in college, please indicate both during school and during the break):

What is the highest level of completed education?

Were there any complications with your birth mother’s pregnancy, delivery, or milestones?

Current occupation/school:

Any additional information that may be helpful to know:

Thanks You!