PATIENT PROFILE FORM
Once you have reviewed Frequently Asked Questions and Treatment Process, and you are interested in becoming a new patient in my holistic psychiatry practice, you can shorten the amount of time I spend typing out the psychiatric history, during the initial phone appointment, by typing your own responses onto this form and e-mailing it to me prior to the phone appointment. (You will need to copy and paste the following form onto a Word document, then fill out the form and e-mail the information to me.) My e-mail is: alice@holisticpsychiatrist.com. I will call you as soon as I have an opening in my schedule. At times, there may be patients whom I will not be able to serve. If that is the case, I will inform you of my decision at the earliest date. Thank you.
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Date:
Name:
D.O.B.:
Age:
Phone:
Cell:
Fax:
E-mail:
Address:
Names and ages of family members:
Contact information for parents (if currently dependent on parents or younger than 18):
I would like to remain on your waiting list until: __ (date).
Your main goal of treatment through holistic psychiatry in one sentence:
Current Medications:
1) __(med): Began: __. Dosage: __. Side effects: __.
2) __(med): Began: __. Dosage: __. Side effects: __.
3) __(med): Began: __. Dosage: __. Side effects: __.
History of Medications used:
4) __(med): Began: __. Dosage: __. Side effects: __.
5) __(med): Began: __. Dosage: __. Side effects: __.
6) __(med): Began: __. Dosage: __. Side effects: __.
Current supplement regimen:
History of supplements used:
History of Present Illness (over the past month):
This includes your condition over the past month: What does it feel like to be in your shoes (i.e. what are your symptoms)? Describe your sleeping pattern. Do you have difficulty falling asleep, staying asleep, or waking up early? Describe your appetite and eating patterns. Please include how you are doing both emotionally and cognitively (memory, attention, planning etc.) Any history of an eating disorder, either anorexia or bulimia? Have you been compliant with treatment? Are you suicidal or homicidal?
Past Mental Health History (Course of Illness):
When did your mental health start to show evidence of illness, e.g. at what age did it all begin? Was it a gradual onset or did it occur due to a specific trauma or event? What have you tried in the past for treatment for your mental health condition. Have you been hospitalized before for these problems?
Past Psychiatric/Medical Hospitalizations:
Past Medical History:
What types of medical problems have you had in the past? What treatment has been given? Past hospitalizations? Surgeries? Infections?
Social History:
Describe your family now and when you were a child. What is going on in your life socially? What type of stress is in your life? What is your occupation? Have you ever been traumatized through abuse or neglect?
Developmental History:
Was your gestation healthy? Were you born premature? Did you have difficulties mentally or physically when you were young? Did you ever get in an accident that broke a bone or hurt your head? Did you experience mental, emotional, or physical traumas growing up? Have you ever had jaundice, Mono, hepatitis, or H. Pylori?
Nutritional History:
What do you like to eat? What would be a typical day for you with respect to the foods that you eat for breakfast, lunch, dinner, and snacks? What types of foods and in what quantities do you eat in the category of junk food, snacks, diet sodas, gum, candies, desserts, and processed foods? Do some foods make you feel tired or wiped out? Did you ever have a dairy or wheat allergy?
Family/Genetic History:
What kind of diseases, both physical and emotional tends to run in your family? What kinds of diseases ended the lives of your relatives? Does substance abuse run in the family?
Review of Systems:
Gastrointestinal System: Have you had a problem with a sensitive stomach, gastric reflux, diarrhea, constipation, or bloating? Have you ever had ulcers or surgery of the G.I. system? e.g. gall bladder removal. Do you have diabetes? Problems with low blood sugars?
Immune System: Do you get sick and catch a cold or flu regularly? Have you taken a great deal of antibiotics in your lifetime? Do you have seasonal or food allergies?
Hormone System: Did you develop smoothly and normally as you transitioned into adolescence? Do you ever wonder if you have a thyroid problem because of problems with weight gain, dry skin, or overall sluggishness? For women: do you have normal cycles?
Musculoskeletal: How are your bones and muscles? Do you ache all over and have problems with weak bones? How are your joints?
Genitourinary: How are your bladder, kidneys, and sexual organs functioning? Do you experience problems with urination, libido, or water balance? Have you had a history of bladder or kidney infections?
Additional Questions: Are you suicidal? To what extent? Are you homicidal? Have you ever cut yourself or mutilated your own body? Have you ever been disconnected with reality and unable to think logically?
Substance Abuse History: What types of substances have you used in the past—cigarettes, alcohol, cocain, marijuana, ecstacy, heroine, etc. How much did you use and when did you begin using them? Why did you use them and how did they make you feel? Do you currently use anything now?
Baseline functioning when well: What are you like when you are “well.” What is it that we are aiming for as a target state of mind? How long ago has it been that you have felt “normal and happy?”
Thank you for taking the time to provide your medical history and for your interest in my holistic psychiatry practice.
Alice W. Lee-Bloem, MD, ABIHM