Northern virginia institute of psychiatry

NORTHERN VIRGINIA INSTITUTE OF PSYCHIATRY PLEASE PRINT. All information obtained here and contained in these records will be held in strictest confidence. No information will be released to other parties or persons without your prior consent authorizing us to release that information to that specific person. Confidential information will only be released without your permission if: 1. there is immediate danger to life, or 2. a valid court order is received for this information. 3. and for insurance billing NAME: _________________________________________________ BIRTHDATE: _________________ PRESENT ADDRESS: ___________________________________________________________________ CITY: _______________________________ STATE: __________________ ZIP: ___________________ HOME TELEPHONE NUMBER: _________________________ LISTED: _____ UNLISTED_________ PLACE OF EMPLOYMENT: _____________________________________________________________ WORK TELEPHONE NUMBER (S): _____________________ _______________________________ SOCIAL SECURITY NUMBER_________ _____ _________ EMEGENCY CONTACT NAME AND TELEPHONE NUMBER: _______________________________ _____________________________________________________________________ INSURANCE COMPANY NAME: ________________________ENROLLMENT DATE: ____________ INSURANCE I.D. NUMBER: _____________________________________________________________ GROUP NUMBER: _______________________ SERVICE NUMBER: ___________________________ SUBSCRIBER FULL NAME: _____________________________________________________________ OTHER INSURANCE? __________________________________________________________________ NAME AND ADDRESS OF PERSON RESPONSIBLE FOR PAYMENT IF YOU ARE NOT COVERED BY ANY INSURANCE COMPANY: _______________________________________________________ Please note that it is our policy to charge the full fee for an appointment, which has been missed, or
an appointment, which has been canceled with less that 72 hours notice.
______________________________________________________________________________________________________ YOUR SIGNATURE: ________________________________________ DATE: ____________________ HOW DID YOU HEAR OF US? _____ PHYSICIAN ____________________________ (name)_____ _____OTHER___________________________________________________(please indicate) NORTHERN VIRGINIA INSTITUTE OF PSYCHIATRY PRESENT OCCUPATION:_______________________________________________________________ EMPLOYED BY:_______________________________________________________________________ WORK ADDRESS:_____________________________________________________________________ YEARS AT THIS OCCUPATION:__________________ HOURS PER WEEK:_________________ I AM NOW:_____________SINGLE_____________ WIDOWED__________ SEPERATED (for how long____?) _____________MARRIED___________DIVORCED (for how long______?) PRESENT LIVING ARANGEMENTS:______ I PRESENTLY LIVE ALONE. ______ I PRESENTLY LIVE WITH SPOUSE NAMED:___________________________________ OCCUPATION:_________________________________________ EMPLOYER:________________________ADDRES:_____________________________________________ ____________________________________ PHONE NUMBER:____________________________________ I PRESENTLY LIVE WITH RELATIVES OR FRIENDS. LIST RELATIONSHIP AND AGE (S) OF ANYONE IN YOUR PRESENT HOUSEHOLD NOT LISTED ABOVE: RELATIONSHIP:__________________________________________________________________________ AGE: BIRTHPLACE (city, state):___________________________AGE:_________________ FATHER’S NAME:_______________________ MOTHER’S NAME___________ AGE:_______ OCCUPATION:_________________________ OCCUPATION:___________________________ PRESENT ILLNESSES:___________________ PRESENT ILLNESSES:_____________________ _______________________________________ __________________________________________ _______________________________________ __________________________________________ CAUSE OF DEATH IF DECEASED:________ CAUSE OF DEATH IF DECEASED:____________ _______________________________________ ___________________________________________ _______________________________________ ___________________________________________ NORTHERN VIRGINIA INSTITUE OF PSYCHIATRY PAST PERSONAL HISTORY (continued) Please list PRESENT ages of brothers and sisters you lived with when you were growing up, beginning with the oldest, and listing yourself, but circle your own age. If any of your brothers or sisters are now dead, please list the year they died next to their age at that time. If any had psychiatric problems, please check the space below their name. (DO NOT SHOW YOUR NAME OR THAT OF ANYONE ELSE, UNLESS THAT INFORMATION IS SPECIFICALLY REQUESTED.) BROTHERS (ages): _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ YOUR EDUCATION LEVEL: Circle highest grade completed. 5 6 7 8 9 10 LIST ANY DEGREES:______________________________________________________ ANY MAJOR (specialty):____________________________________________________ YOUR MEDICAL HISTORY: NAME, ADDRESS AND PHONE NUMBER OF FAMILY PHYSICIAN: ________________________ __________________________ ________________________ __________________________ OTHER PHYSICIANS YOU HAVE CONSULTED, OR CLINICS YOU HAVE ATTENDED IN THE PAST YEAR: NAME ______________________ _______________________________________ ______________________ _______________________________________ ______________________ _______________________________________ ______________________ _______________________________________ NORTHERN VIRGINIA INSTITUTE OF PSYCHIATRY YOUR MEDICAL HISTORY (continued): PAST HOSPITALIZATIONS, if any. List the most recent first. DATE NUMBER PAST PSYCHIATRIC TREATMENT, 9if any). List name of psychiatrist or clinic starting with the most recent: APPROX. NAME OF PSYCHIATRIST, CLINIC OR HOSPITAL _______________________________________________ _______________________________________________ _______________________________________________ List any medications or substances you have ever had an allergic reaction to: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______ AS FAR AS I KNOW, I AM NOT ALLERGIC TO ANY MEDICATION OR SUBSTANCE. PRESENT MEDICATIONS: (List names of any medication you are presently taking.) NAME NORTHERN VIGINIA INSTITUTE OF PSYCHIATRY YOUR MEDICAL HISTORY: (continued) Please check YES or NO to indicate if you have or have not ever experienced any of the following: YES ANY HEAD INJURY AFTER WHICH YOU WERE UNCONSCIOUS DIFFICULTY FALLING ASLEEP MOE THAN ONE NIGHT IN A ROW STOMACH PAIN THAT LASTED MORE THAN A WEEK HAD MORE THAN YOUR USUALAMOUNT OF ENERGY FOR A WEEK DRANK MORE ALCOHOL THAN YOU THOUGHT YOU SHOULD FELT SAD AFTER THE DEATH OF SOMEONE YOU LIKED BEEN TOLD YOU HAD HIGH BLOOD PRESSURE OR HEART TROUBLE NORTHERN VIRGINIA INSTITUTE OF PSYCHIATRY MEDICATION: Please check if you have ever used, or have ever taken, any of the drugs or medications listed below: ___ Aldomet ___ Hydropes ___ Metatensin ___ Naquivil ___ Regrotron ___ Renese-R ___ Salutensin ___ Ser-Ap-Es ___ Solfo-Serpine ___ Pertofrane ___ Presamine ___ Sinequan ___ Supergrass ___ Fluoxetine ___ Cocaine

Source: http://novapsychiatry.com/NVIP_Registration.pdf