Email

Gender

Social Security Number

Medicare ID Number

Secondary Insurance

ID Number

Prescription Plan

ID Number

Line

Name of primary contact

Relationship to the patient

Name of secondary contact

Relationship to the patient

Line

Referred by

Name of primary care provider

Reason for this consultation

Line

Patient's place of birth

Education level

Military service

Type of employment

Marital / Relationship status & How long

Children and ages (seperated by a comma)

Parents, age & cause of death (if applicable)

Siblings, age & cause of death (if applicable)

Mentionable instances of family psychiatric history

If the patient has seen a psychiatrist or neurologist before, why?

Medical history (e.i. heart, lungs, thyroid, blood, arthritis, diabetes, hearing loss, vision. issues, stroke, lyme disease, COVID-19, head trauma, etc.)

Hospitalizations

MRI or CT scan history, where and when (if applicable)

Drinking quantity and history

Smoking quantity and history

Cannabis quantity and history

Who helps with these activities?

Are you basically satisfied with your life?

Have you dropped many of your interests and activities?

Do you feel your life is empty?

Do you often get bored?

Are you in good spirits most of the time?

Are you afraid something bad is going to happen to you?

Do you often feel helpless?

Do you prefer to stay at home or going out and doing new things?

Do you feel that you have more memory problems than most

Do you think it's wonderful to be alive now?

Do you feel worthless in your current state?

Do you feel full of energy?

Do you feel your situation is hopeless?

Do you think most people are better off than you?

Name of person completing this form

Relationship to the patient

patient information sheet

Phone: (631)-737-6434 | Fax: (631)-738-1226