New Patient - Clinicals | Psychosomatic Institute of San Antonio

Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Reason for your visit:(Required)

Past Medical history

Do you suffer or have suffered in the past of (please check all that apply):

Past Medical history

Parkinson’s disease

Multiple Sclerosis

Head injury

Chronic headaches

Stroke

Gastric disease

Seizures

Glaucoma

Cancer

Hypertension

Past Medical history

Disabled

Chronic pain

High Cholesterol

Thyroid disease

Arthritis

Fibromyalgia

Diabetes

Lung problems

Please list the name of your physicians and their information if available:

Primary care physician:(Required)

Others by specialty(Required)

List previous hospitalizations or surgeries:(Required)

Past psychiatric history:

Previous treatments:(Required)

Yes

With another psychiatrist:(Required)

Yes

Currently in therapy:(Required)

Yes

Previously in therapy:(Required)

Yes

Ever hospitalized for a psychiatric condition:(Required)

Yes

If yes, how many times:(Required)

When and where were the first and the last hospitalizations:(Required)

Marital status:(Required)

Single

Married

Divorce

Separated

Widow

Name and relation of persons living with you now:(Required)

Nicotine use:

Currently(Required)

Yes

If yes, how often:

Alcohol use:

Currently(Required)

Yes

If yes, how often:

Drug use:

Currently:(Required)

Yes

If yes, how often:

Other addictive problems (gambling, video games, pornography, etc.):(Required)

Yes

If yes, please describe:

Legal problems in the past:(Required)

Yes

If yes, please describe:

Current legal problems:(Required)

Yes

If yes, please describe:

Higher level of education?(Required)

Problems in school?(Required)

Yes

Current occupation (title):(Required)

Place of work:(Required)

Do you practice a religion?(Required)

Yes

If yes, descibe:

Do you have a church affiliation?(Required)

Yes

If yes, descibe:

What is your spiritual background?(Required)

Anyone in your family suffered, diagnosed or treated for a psychiatric condition(Required)

Yes

Parents alive:(Required)

Yes

Number of siblings:(Required)

Siblings ill or deceased?(Required)

Yes

If yes, explain:

Allergies to medications and reactions:(Required)

Are you having general health symptoms now? If so, describe:(Required)

Please list all the medications you take and doses if known:(Required)

Preferred pharmacy:

Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

MEDICATION HISTORY

Previous medications (please check if have taken in the past and note dose and approximate length of time taken below):

Anafranil (clomipramine)

Celexa (citalopram)

Cymbalta (duloxetine)

Desyrel (trazodone)

Effexor (venlafaxine)

Elavil (amitriptyline)

Emsam (selegiline)

Fetzima (levomilnacipram)

Lexapro (escitalopram)

Luvox (fluvoxamine)

Marplan (isocarboxazid)

Norpramin (desipramine)

Nuedexta (dextrometorphan/quinine)

Pamelor (nortriptyline)

Lithium carbonate Dose/Strength

Depakote (valproic acid)

Lamictal (lamotrigine) Dose/Strength

Abilify (aripiprazole)

Clozaril (clozapine)

Fanapt (iloperidone)

Geodon (ziprazidone)

Haldo (haloperidol)

Invega (paliperidone)

Latuda (lurasidone)

Mellaril (thioridazine)

Navane (thiothixene)

Orap (pimozide)

Perphenazine

Ambien (zolpidem)

Ativan (lorazepam)

Belsomra (suvorexant)

Buspar (buspirone)

Previous medications (please check if have taken in the past and note dose and approximate length of time taken below):

Dalmane (flurazepam)

Klonopin (clonazepam)

Lunesta (Eszopiclone)

Parnate (tranylcypromine)

Paxil (paroxetine)

Pristiq (desvenlafaxine)

Prozac (fluoxetine)

Remeron (mirtazapine)

Savella (milnacipram)

Serzone (nefazodone)

Sinequan (doxepin)

Tofranil (imipramine)

Trintellix (bortioxetine)

Viibryd (vilazodone)

Vivactil (protriptyline)

Wellbutrin (bupropion)

Zoloft (sertraline)

Tegretol (carbamazepine)

Topamax (topiramate)

Prolixin (fluphenazine)

Rexulti (brexpiprazole)

Risperdal (risperidone)

Saphris (asanepine)

Seroquel (quetiapine)

Stelazine (trifluoperazine)

Triavil

Thorazine (chlorpromazine)

Previous medications (please check if have taken in the past and note dose and approximate length of time taken below):

Vraylar (Cariprazine)

Zyprexa (olanzapine)

Restoril (temazepam)

Rozerem (ramelteon)

Sonata (zaleplon)

Xanax (alprazolam)

Halcion (triazolam)

Serax (oxazepam)

Vystaryl (hydroxyzine)

Adderall (XR) (amphetamine mix)

Armodafinil (nuvigil)

Concerta (methylphenidate)

Daytrana (methylphenidate)

Dexedrine (dextroamphetamine)

Evekeo (amphetamine)

Focalin (dexmethylphenidate)

Metadate (methylphenidate)

Mydayis (amphetamine mix)

Phentermine

Provigil (modafinil)

Ritalin (methylphenidate)

Strattera (atomoxetine)

Vyvanse (lisdexamphetamine)

Aricept (donepezil)

Exelon (rivastigmine)

Namenda (memantine)

Reminyl (galantamine)

List

Drug name

Dose

Strength

For every selected drug, please share dose and strength.

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New Patient – Clinicals

Take the first step towards genuine mental well-being today.

Past Medical history

Please list the name of your physicians and their information if available:

Past psychiatric history:

Nicotine use:

Alcohol use:

Drug use:

Preferred pharmacy:

MEDICATION HISTORY

Your Pathway to Mental Health Mastery.

Your Pathway to Mental Health Mastery.

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