Wisconsin Psychiatric Institute & Clinics Psychiatry
Why are you coming to UW Psychiatry and did someone refer you to us? __________________________________________________________________________________________________ Psychiatric History:
Have you seen a psychiatrist or therapist in the past?
Please list below
__________________________________________________________________________________________________ Have you ever been diagnosed with a psychiatric or mental health disorder? YES NO
Attention Deficit/Hyperactivity Disorder
Y N Pathological Gambling
Addictions of any kind Y N Have you ever been hospitalized for mental health treatment? If you indicated yes, please explain:
Please circle the psychiatric medication that you have taken in the past: Buspar – buspirone
Please list any additional psychiatric medication that you have taken in the past: __________________________________________________________________________________________________
Family Psychiatric History and Medical History
Have any of your family members suffered from any of the above listed psychiatric disorders? Please explain: __________________________________________________________________________________________________
Current or Chronic Illnesses: __________________________________________________________________________________________________
__________________________________________________________________________________________________ Please list current medications and doses including over the counter medications and herbs and vitamins: __________________________________________________________________________________________________ __________________________________________________________________________________________________
Allergies and reaction ________________________________________________________________________________ Do you use tobacco products and if so how much?_________________________________________________________
How often and what kind of caffeinated beverages do you use? ______________________________________________ How many beer, glasses of wine, mixed drinks, shots do you typically have in an average week?
__________________________________________________________________________________________________ Have you ever felt that you need to cut down on your drinking? YES NO Have people criticized your drinking? YES NO
Have you ever felt guilty about your drinking? YES NO Have you ever felt a need to have a drink in the morning to steady your nerves? YES NO
Have you ever had a DWI? YES NO Do you smoke marijuana or use any other drugs and how often? _____________________________________________ Are you currently involved in any legal problems? YES NO Please explain if answered yes:
__________________________________________________________________________________________________ Social History: Where did you grow up and explain your family of origin (parents, siblings) and briefly describe your childhood:
__________________________________________________________________________________________________ Have you been a victim of abuse? YES NO
__________________________________________________________________________________________________ Current Living situation: ______________________________________________________________________________ Do you feel safe in your current living situation? YES NO __________________________________________________
Marital History and number and ages of children if applicable_________________________________________________
Education and current employment______________________________________________________________________ Current support systems_______________________________________________________________________________ Please list any additional information that you think I should know or that you would like to discuss at today’s visit.
What are your goals for psychiatric treatment?
The objective of this paper is to discuss how to measure the role ofintergenerational transfers for wealth using cross-national comparabledata sets constructed by the Luxembourg Wealth Study (LWS) project. The most obvious use of the LWS data for studying intergenerationaltransfers is to estimate econometric models that can be used to predict“end of life” wealth. If the original data is of pan
H1N1 Influenza Vaccine School Pre-Registration Form Information about Child to Receive Vaccine (Please Print) STUDENT’S NAME (Last) STUDENT’S DATE OF BIRTH Month_________ Day________ Year __________ MOTHERS MAIDEN NAME (LAST) STUDENT’S AGE STUDENT’S GENDER ADDRESS CITY PARENT/GUARDIAN DAYTIME PHONE NUMBER: SCHOOL NAME/GRADE Parent/Guardian’s