Psychiatric History
Long Hollow Family Practice
Thank you for taking the time to answer these questions. This information is confidential and will help me prepare for our visit and provide better care for you. 
Thank you,
Candyce Miller, FNP-BC, PMHNP-BC
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Full Name: *
Today's date *
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Birthdate: *
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What name do you like to be called? *
Gender at birth *
Phone Number: *
Email Address *
What is your reason for making this appointment?  *
Which of these conditions, if any, have you been PREVIOUSLY diagnosed with?  *
Required
List any other psychiatric conditions that you have been diagnosed with that aren't listed above. 
Please read the following information about your appointment if you are requesting an ADHD evaluation or treatment for ADHD:

ADHD evaluations often require 2 appointments to complete the assessment. The first visit is a comprehensive psychiatric evaluation, not specific to ADHD. The second visit expands on the first evaluation to further assess for ADHD symptoms. Other mental health issues such as depression, anxiety, PTSD, insomnia, and bipolar disorder can also impact an individual's focus and concentration and must also be considered when making an ADHD diagnosis. Referral for outside neuropsychological testing will sometimes be made, if needed, for additional diagnostic clarity. 

If you have already been diagnosed with ADHD by another provider, please provide records of this evaluation prior to your appointment. Candyce will also complete her own evaluation to confirm the diagnosis. 

If you are already taking stimulants for ADHD, records from the previous prescriber will also need to be received before Long Hollow Family Practice will be able to take over that prescription.

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Which of these medications, if any, do you remember trying IN THE PAST (not current medications)? *
Required
List any other psychiatric medications you have taken IN THE PAST that aren't listed above.
Use this space to explain why each of the medications noted above were stopped or any reactions you have had to psychiatric medications.
Have you ever had psychiatric genetic testing done? (such as the GeneSight Test) *
List all of your current medications and dosages. Please include medications taken for your mental health, medications taken for medical conditions, and any over-the-counter medications.  *
Who has been prescribing your psychiatric medications? *
Do you see a therapist for talk-therapy?  *
If you see a therapist, who do you see?
List all of your medication allergies. *
Have you ever been hospitalized for your mental health? *
If yes, please explain.
How much alcohol do you drink, if any?  *
How much caffeine do you drink, if any? *
Do you use any nicotine or tobacco products? If yes, what kind and how much each day?  *
Do you use any marijuana, THC, or CBD? If yes, what kind and how much?  *
Please list any other substances or recreational drugs that you use. *
Do you have a history of any type of addiction? If yes, please explain.  *
List all of the surgeries that you have had. *
Have you ever been diagnosed with a heart problem?  *
If yes, please explain.
Have you ever had an abnormal EKG? *
If yes, please explain.
Have you ever been diagnosed with asthma, COPD, or another lung disease? *
If yes, please explain. 
Have you ever had head or brain trauma? *
If yes, please explain. 
Have you ever had a seizure? *
If yes, please explain
Have you ever been diagnosed with glaucoma or elevated pressure in your eyes? *
Have you ever been told that your kidneys or liver are not functioning well or had abnormal labs related to your kidneys or liver?  *
If yes, please explain
List all of your past or ongoing medical problems not already described above (such as high blood pressure, diabetes, stroke, cancer, thyroid problems, gastrointestinal disorders, migraine headaches, vitamin deficiencies, chronic pain, etc.). *
Has anyone in your family died suddenly from a heart problem OR before the age of 40 from a heart problem? *
If yes, please explain.
List any psychiatric conditions in your family and who has had them.  *
List any medical problems in your family and who has had them (such as heart problems, diabetes, high blood pressure, cancer, etc.).  *
Has anyone in your family suffered from an addiction? *
If yes, please explain.
Has anyone in your family attempted or completed suicide? *
If yes, please explain. 
Were there any complications with your mother's pregnancy or delivery of you? *
If yes, please explain.
Did you meet all of your childhood developmental milestones on time, such as walking and talking? *
If no, please explain. 
What is your occupation? *
What is the highest level of education you completed? *
What is your relationship status? *
What is your race and/or ethnicity? *
Use this space to share anything else that you would like Candyce to know about you (such as sexual orientation, preferred pronouns, or anything else that feels important to you). 
Over the last 2 weeks, how often have you been bothered by the following problems?
 *
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen

If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Clear selection

Over the last 2 weeks, how often have you been bothered by any of the following problems?

 *
Not at all
Several days
More than half the days
Nearly every day
Less interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself–or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite–being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself

If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Clear selection

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:
A serious accident or fire
A physical or sexual assault
Physical or sexual abuse
An earthquake or flood
A war
Seeing someone be killed or seriously injured
Having a loved one die through homicide or suicide
 
Have you ever experienced this kind of event? 
 *
IF you answered YES to experiencing a traumatic event, please also answer the following questions about how that event is affecting you: 

In the PAST MONTH, how much were you bothered by:
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing, and unwanted memories of the stressful experience?
Repeated, disturbing dreams of the stressful experience?
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Avoiding memories, thoughts, or feelings related to the stressful experience?
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Trouble remembering important parts of the stressful experience?
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Blaming yourself or someone else for the stressful experience or what happened after it?
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Irritable behavior, angry outbursts, or acting aggressively?
Taking too many risks or doing things that could cause you harm?
Being "superalert" or watchful or on guard?
Feeling jumpy or easily startled?
Having difficulty concentrating?
Trouble falling or staying asleep?
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