College of medicine, jacksonville

COLLEGE OF MEDICINE – Jacksonville 580 W 8th St T-2 6th Fl Ste 6005 Department of Psychiatry Jacksonville, FL 32209 Division of Adult Psychiatry Phone 904-383-1038 Adult Patient History Questionnaire
Name:
Preferred Name:
Date of Birth:
Referred By:
What Are Your Concerns That Brought You In Today?
Please Circle All Symptoms That You Are Currently Experiencing:
Sad Mood
Concentration/Memory Fear of Leaving the Repetitive Thoughts Seeing Images Others Do Not Early Morning Waking Excessively Orderly Bizarre Ideas
Medications: Please list all medications or supplements that you are currently taking.
Include psychiatric and medical medications.
Medication
Doses per day
(AM, twice daily, at bedtime, etc)
Have you experienced a head injury? If so, please explain what happened, your age, and if you were
unconscious:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Primary Care Physician:
Clinic Address and Phone Number:

Current Medical Diagnoses
i.e. asthma, diabetes, seizures, etc 1.
Previous Surgeries

Previous Hospitalizations

Past Psychiatric History
Have you ever seen a psychiatrist? If so, please provide information about providers, dates, and treatment
rendered.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever seen a psychologist?_________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever seen a therapist (i.e. LMHC, LCSW, LMFT)?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever been hospitalized for psychiatric reasons? If so, where and when?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Developmental History:
Any Learning Disabilities (i.e. reading, dyslexia, writing, math, etc)?:
_________________________________________________________________________________________
Attended Special Education Classes?:
_________________________________________________________________________________________
Received Any Developmental Services (i.e. physical, speech, occupational therapy, etc)?:
_________________________________________________________________________________________
Social History:
Marital Status: Single Married Divorced Widowed Partnered
Lives With (Name, Age, and Relation to Yourself):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Highest Grade Attended:______________________________________________________________________
Occupation and Employment (specialty, where you work, and how long):
__________________________________________________________________________________________
__________________________________________________________________________________________
Military History:____________________________________________________________________________
Arrest History or Pending Legal Issues (i.e. divorce, disability, bankruptcy, etc):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Family History: Please indicate if there is a family history of the following conditions and WHO is affected
with the condition.
Anxiety

Substance Abuse History: Please circle all that you have used in the past 2 years:
Alcohol
Opiates (heroin, pain killers, methadone) Benzodiazepines (Xanax, Klonipin, Ativan, Valium) Over the Counter (cough syrup, triple C’s)
In the past two years, there have been one or more episodes of memory loss due to substance abuse? Yes or No
There are personality changes due to the use of substances. Yes or No
In the past 5 years, there has been one or more arrest due to substance or alcohol use? Yes or No
Someone close to you thinks you may have a serious substance abuse problem. Yes or No
There is a history of serious problems with the use of substances. Yes or No
There is a history of substance abuse treatment. Yes or No

Past Psychiatric Medication
Anti Depressants
Response (Good,
Antipsychotic
Response
Fair, Poor)
(Good, Fair,
Poor)
Mood Stabilizers
ADHD Medications
AntiAnxiety
Miscellaneous
Antipsychotic
Other Medications

Source: http://ufhealthjax.org/forms/psychiatry-dupont-adult-patient-questionnaire.pdf