Follow-Up Visit Form
Email address *
Name: *
Your answer
Date: *
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YYYY
Overall, how SEVERE were your PSYCHIATRIC symptoms, in the LAST WEEK? *
In the past week, how much have PSYCHIATRIC SYMPTOMS interfered with or caused difficulty in your life, such as: *
How would you rate your overall quality of life this week? *
Please note any major changes in your life since last visit: *
Required
Current tobacco use, in Packs Per Day: *
Your answer
Current alcohol use, servings per week: *
Your answer
Illicit substance use since last visit: *
Your answer
What describes your pattern of taking psychiatric medications since last visit? *
MED CHANGES from other doctors since last visit: *
Your answer
What side effects have you had from Psychiatric Medicine, in the last week? *
Your answer
SLEEP OVER THE LAST WEEK: Usual # Hours: *
Your answer
Problems with sleep over the last week: *
Required
ENERGY/ACTIVITY LEVEL OVER THE LAST WEEK: *
Since your last visit, have you had thoughts of killing yourself? *
If YES, do you have a PLAN? *
If YES, do you have the means to carry out your plan? *
If YES, do you INTEND to carry out your plan? *
Since your last visit, have you done anything, started to do anything, or prepared to do anything to end your life? *
Since your last visit, have you done anything (out of the ordinary) that could have killed you? *
Since your last visit, have you heard voices telling you to harm or kill yourself or someone else? *
Since your last visit, have you had serious or persistent PLANS or INTENTIONS of harming someone else? *
What else is important to know for this visit? *
Your answer
Review of Systems Checklist: (Please any that you have had in the LAST 2 WEEKS)
Constitutional: *
Required
Eye: *
Required
Ears/Nose/Throat: *
Required
Cardiovascular: *
Required
Respiratory: *
Required
Gastrointestinal: *
Required
Genitourinary: *
Required
Musculoskeletal: *
Required
Skin/Breast: *
Required
Neurologic: *
Required
Endocrine: *
Required
Blood System: *
Required
Immunologic: *
Required
If you have had any insurance changes since your last visit, please go to mindtime.net and click the pink button "Insurance Changes" to document these prior to your visit. Thank you very much!
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