Psychiatric Intake Form (Page 3 of 5) in pdf

Psychiatric Intake Form Page 3

How would you describe your current sleep/rest? (circle)

Poor

Fair

Good

Very Good

Please describe any sleep concerns you are currently having:_________________________________

How would you describe your current eating habits/appetite? (circle)

Poor

Fair

Good

Very Good

Please describe any eating/appetite concerns you are currently experiencing: _____________________

How often do you exercise? ____________________________________________________________

What kind of exercise do you participate in? _______________________________________________

Are you currently experiencing any of the following: (circle)

Sadness

Anxiety

Panic

Depression

Grief

If yes, how long have you been experiencing these feelings? __________________________________

Are you currently experiencing any chronic pain? If yes, please describe: ________________________

How often do you drink alcohol? (circle) Never

Daily

Weekly

Monthly

Other:______________________

How often do you participate in recreational drug use? (circle)

Never

Daily

Weekly

Monthly

Other:______________________

How would you describe your social life? _________________________________________________

If you are in a romantic relationship, how would you describe the relationship currently?

Psychiatric Intake Form Page 3