Date

Wisconsin Psychiatric
Institute & Clinics
Psychiatry
Name______________________________________________________
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?

Source: http://www.psychiatry.wisc.edu/Adult%20New%20Patient%20Form.pdf