Patient Intake History

Patient Intake Form
General Information
Date*

MonthDayYear
Date
Intake Clinician Name:

First NameLast Name
DEPRECATED. USE THE NEW NAME FIELD - Name of the Patient (Legal Name)*

First NameLast Name
Patient's Legal First Name*
Patient's Legal Last Name*
If the patient is not being interviewed, enter the name of person being interviewed

First NameLast Name
Relationship to Patient
Please select the type of submission:*

BaselineRe-evaluation
I. Patient Information
Patient's Preferred Name (if different than legal name)

First NameLast Name
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Format: 000 000 0000 .
Date of Birth*

MonthDayYear
Date
Confirm Date of Birth*

MonthDayYear
Date
DOB does not match!
Patient Age
Highest Level of Education or Current Grade
Gender at Birth

MaleFemale
Pronouns
Race
Ethnicity
Handedness

Right-handedLeft-handedAmbidextrousOther
If left-handed: Other left-handed family members?

YesNo
If yes, specify who in the family is left-handed?
First language learned and spoken fluently?
Second language learned and spoken fluently? (if applicable)
Currently, what is the patient’s primary language?
Location of the patient/caregiver during the intake:
E.g. In-clinic, home, office
II. Referral Information
Referral Source

The patient is being evaluated due to difficulties with (check all that apply):

Rows	Yes	Please explain
Cognitive / Language Functioning
Behaviors, Behavioral Regulation or Sleep
Mood Symptoms
Social Functioning
Motor Functioning
Other

Rows	Patient Concerns	Parent Concerns	Teacher Concerns	Notes
Reading
Writing
Math
Spelling
Verbal learning disability
Nonverbal learning disability
Social Skills
Emotions
Behavior
Attention deficits
Other

Additional Information
III. History of Presenting Problems
Please provide a history of the patient presenting problems including all relevant information that may be related to the patient's symptoms and / or deficits:
Was the patient aware of their symptoms/probes when they first began:

YesNo
If the patient was aware and can still communicate ask him/her to describe these initial symptoms/problems; if not ask a family member or reliable source for a description:
Was the onset of these symptoms/problems:

InsidiousAbrupt
Have these symptoms/problems:

ProgressedRemained relatively stable
If they have progressed have these symptoms progressed more like:

A gradual slopeDownward staircase
If progressive to the point where the patient is no longer independent with most basic ADLs such as bathing and toileting (exclusive of purely physical or motor causes), what was the period of time from the initial presentation of these symptoms/problems and the onset of dependency with most ADLs:
Time from onset to changes in ADLs: blanks or N/A
On a day-to-day basis are these symptoms/problems:

About the sameFluctuate dramatically
During the period between now and when these symptoms first began have you or the patient noted any visual hallucinations:

YesNo
If the patient has had visual hallucinations, did these occur only when the patient had an infection (e.g. from a UTI or pneumonia or when medically hospitalized):

YesNo
Age of patient when consultation was first obtained related to the initial symptoms/problems: age
Additional information:
IV. Medications
Current Medications (please specify the date if any medications were added or changed within the past 4 months)
Past Medications
V. Treatments, Therapies, and Interventions
In the following section, please indicate any past or present treatment or therapy interventions the patient has undergone. It is important to include details such as the dates, duration of the intervention, and response to the treatment. These details should be included in the Notes column.

None

Treatment/Therapy Type

Rows	Current	Past	Notes
Psychotropics
Psychotherapy
School Counseling
Psychiatric hospitalization
ECT (Electroconvulsive Therapy)
Speech Therapy
Occupation Therapy
Physical Therapy
Cognitive Rehabilitation
ABA or Behavioral Therapy
Social Skills Group
Early Intervention
IEP (Individualized Education Program)
504
FB/BIP School Behavior Plan
Other School Services or Accommodations
Tutoring

Others
Psychotropics

CurrentPastN/A
Notes (e.g. age started)
(e.g., age started)
Psychotherapy

CurrentPastN/A
Notes
(e.g., age started)
School Counseling

CurrentPastN/A
Notes
(e.g., age started)
Psychiatric hospitalization

CurrentPastN/A
Notes (e.g. number of times)
(e.g., age started)
ECT (Electroconvulsive Therapy)

CurrentPastN/A
Notes
(e.g., age started)
Speech Therapy

CurrentPastN/A
Notes (e.g. school or private)
(e.g., age started)
Occupational Therapy

CurrentPastN/A
Notes (e.g. school or private)
(e.g., age started)
Physical Therapy

CurrentPastN/A
Notes (e.g. school or private)
(e.g., age started)
Cognitive Rehabilitation

CurrentPastN/A
Notes
(e.g., age started)
ABA or Behavioral Therapy

CurrentPastN/A
Notes (e.g. school or private)
(e.g., age started)
Social Skills Group

CurrentPastN/A
Notes (e.g. school or private)
(e.g., age started)
Early Intervention

CurrentPastN/A
Notes
(e.g., age started)
IEP (Individualized Education Program)

CurrentPastN/A
Notes
(e.g., age started)
504

CurrentPastN/A
Notes
(e.g., age started)
FBA/BIP School Behavior Plan

CurrentPastN/A
Notes
(e.g., age started)
Other School Services or Accommodations

CurrentPastN/A
Notes
(e.g., age started)
Tutoring

CurrentPastN/A
Notes
(e.g., age started)
VI. Review of Neurodiagnostic Studies and Labs
Neurodiagnostic and Neuroimaging Studies

None
FDG PET Study of the Brain
PET study of the brain     Date
Completed but not found in records
Unremarkable
Abnormal due to:
Generalized hypoperfusion
Posterior hypoperfusion
Medial hypoperfusion
Left-sided hypoperfusion
Right-sided hypoperfusion
Hyperfusion
Other
Findings from other types of PET studies (e.g. Amyloid or TAU PET)
CT or MRI of the Brain
CT   MRI of the brain       Date
Completed but not found in records
Unremarkable for age
Abnormal due to:

Enlarged ventricles/sulci

PVWMD

DWMD

Thalamic enhancement

General atrophy

Specific or asymmetric atrophy

Locations:   Click to enter text.

Lesion/tumors:   Click to enter text.

Calcifications:   Click to enter text.

Other:    Click to enter text.
SPECT, QEEG or EEG
SPECT   QEEG   EEG       Date
Completed but not found in records (Upload files below)
Normal
Abnormal due to:
Generalized slowing:
Anterior   Posterior    Right hemisphere

Laterized slowing
Anterior right        Anterior left   Posterior right   Posterior left

Sharp waves

Anterior left   Posterior left  Posterior right   Medial   Bi or Tri-Phasic

Other
File Upload

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CSF Analysis / LP
CSF Analysis   LP          Date
Completed but not found in records
Normal
Abnormal due to:
Decreased Abeta 1-42:     Click to enter text.
Elevated total tau:   Type a label
Elevated phophotau:.
Pressure elevated
Pressure decreased
Evoked potential abnormalities:
Visuals
Auditory
Tactile
Other:   Type a label
Other Neurodiagnostic Assessments
Prior Cognitive and Academic Testing Results
Prior Cognitive and Academic Testing Results

N/AUnknown
Cognitive Testing

Completed but not found in records (please upload test results)Never completed
File Upload

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Assessment or Index

Rows	Date of Eval	Score	Descriptor
MMSE
3MSE
Verbal Comprehension (VCI)
Visual Spatial (VSI)
Fluid Reasoning (FRI)
Perceptual Reasoning (PRI)
Working Memory (WMI)
Processing Speed (PSI)
FSIQ
Other:

Academic/Learning Disability Testing

Completed but not found in records (please upload test results)Never completed
File Upload

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Learning Disability Test Results

Rows	Date of Eval	Score	Descriptor
Overall reading:
Reading fluency
Reading comprehension:
Phonological decoding:
Writing
Spelling
Overall Math
Calculations
Applied Math
Expressive Language
Receptive Language
Other:

Additional Assessments, Scores, and Other Information:
Past and/or Current Cognitive and Academic Difficulties:

N/AUnknown
Laboratory Results

No recent labsNo chemistry labsNo CBC labs
Chemistry Profile
Date

Notable for:
Potassium level::     Click to enter text.
Sodium Na level:   Click to enter text
Chloride level   Click to enter text
Calcium level:   Click to enter text
Phosphorous level:   Click to enter text
Carbon dioxide:   Click to enter text
BUN:   Click to enter text
Creatinine level:   Click to enter text
B/C Ratio level:   Click to enter text
Blood glucose level:   Click to enter text
Direct bilirubin level:   Click to enter text
Total bilirubin level:   Click to enter text
ALP level:   Click to enter text
GGT level:   Click to enter text
ALT:   Click to enter text
AST level:   Click to enter text
Other:   Click to enter text
CBC
Date
With Differential
Without Differential
Normal

Notable for:
WBC level::     Click to enter text.
RBC level:   Click to enter text
level   Click to enter text
Hemoglobin level:   Click to enter text
Phosphorous level:   Click to enter text
Carbon dioxide:   Click to enter text
BUN:   Click to enter text
Creatinine level:   Click to enter text
B/C Ratio level:   Click to enter text
Blood glucose level:   Click to enter text
Direct bilirubin level:   Click to enter text
Total bilirubin level:   Click to enter text
ALP level:   Click to enter text
GGT level:   Click to enter text
ALT:   Click to enter text
AST level:   Click to enter text
Other:   Click to enter text
Additional Lab Results
File Upload

You can upload your lab and other study results
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VII. Neurodevelopmental, Neurological, Psychiatric and Medical History
Pregnancy and Birth History

N/AUnknownUnremarkable/noncontributory
Mother’s age at patient’s birth:
Pregnancy complications

YesNo
Premature birth

YesNo
If yes, gestational age (in weeks)
e.g. 30 weeks
Birth/delivery complications

YesNo
If yes, please explain
Birthweight (lbs, oz)
e.g. 6 lbs 2 oz
Additional information
Developmental History

No developmental delays or concerns

Rows	Yes	No	Notes
Difficult to soothe as infant
Gross motor delays
Fine motor delays
Expressive language delays
Receptive language delays
Social development delays
Repetitive behaviors or interests
Other autistic indicators
Emotional problems
Behavioral problems
Other

Rows	Yes	No	Notes
Difficult to soothe as infant
Gross motor delays
Fine motor delays
Expressive language delays
Receptive language delays
Social development delays
Repetitive behaviors or interests
Emotional problems
Behavioral problems
Other

Neurodevelopmental Signs of Possible Autism

From Birth to Age 2
Is or was there reduced non-verbal communication such as pointing or gesturing?
Is or was there reduced or atypical eye contact?
Is or was there reduced affective expression or lack of smiling?
Is or was there diminished interested in social interaction?
Is or was there reduced responses when calling their name?
Other Autistic indicators from 2-5 years
Is or was there a loss of language or words?
Is or was there a limited use of words and phrases?
Is or was there unusual, idiosyncratic or odd use of language and words?
Is or was there a decreased interest and/or limited interaction with peers?
Is or was there a restriction in imaginative play?
Is or was there unusual preoccupations and/or interest in objects or parts of objects?
Is or was there compulsions and/or a high degree of ritualistic behaviors?
Was the patient diagnosed with ADHD?

YesNo
Additional Information
Was the patient diagnosed with an intellectual disability?

YesNo
Additional Information
Was the patient diagnosed with a learning disability?

YesNo
Additional Information
Patient's Neurological History (Skip if this section has been completed in the Patient History Form)
None

Notable for:
AVMs
Brain injury with LOC
Brain injury without LOC
Cerebellum Dysfunction
Cognitive disorder (mild)
CVA ischemic
CVA hemorrhagic
Ischemic microvascular disease
Dementia
Demylenating disorder (atypical)
Gullain-Barre Syndrome
Hemiparesis (left)
Hemiparesis (right)
Hemiplegia (left)
Hemiplegia (right)
Migraines
Meningitis (bacterial)
Meningitis (viral)
Multiple Sclerosis
Muscular Dystrophy
Neoplasms (primary)
Neoplasms (secondary)
Neuropathy
Parkinson's Disease
PSP
Seizures
Spinal Cord Compression
TIAs
Additional information about the patient’s neurological history:
Family's Neurological History (Skip if this section has been completed in the Patient History Form)
Non-Contributory

Notable for:
Early Dementia < 65 y/ois
Parkinson's Disease
Stroke
Multiple Sclerosis
Other   Type a label
Family's Neurological History Additional Information
Patient's Reported Psychiatric History (Skip if this section has been completed in the Patient History Form)
None

Notable for:
Alcoholism
Anorexia
Anxiety
Autism Spectrum Disorder
Behavior Problems
Bipolar Disorder
Body Dysmorphic Disorder
Bulimia
Depression (episodic)
Social Pragmatic Difficulties
Disruptive Mood Dysregulation Disorder (DMDD)
Somatization Disorder
Dysthymia
OCD
Psychosis (brief)
Psychosis (unspecified)
PTSD
Repetitive Behaviors
Sensory Processing Disorder
Schizoaffective Disorder
Schizophrenia
Selective Mutism
Suicidal Behaviors
Substance Abuse
Other
Additional Information
Family's Psychiatric History (Skip if this section has been completed in the Patient History Form)
None

Notable for:
Alcoholism
Anorexia
Anxiety
Autism Spectrum Disorder
Behavior Problems
Bipolar Disorder
Body Dysmorphic Disorder
Bulimia
Depression (episodic)
Social Pragmatic Difficulties
Disruptive Mood Dysregulation Disorder (DMDD)
Somatization Disorder
Dysthymia
Intellectual Disability
OCD
Oppositional Defiant Disorder (ODD)
Panic Disorder
PTSD
Personality Disorder
Phobias
Psychosis (brief)
Psychosis (unspecified)
Repetitive Behaviors
Sensory Processing Disorder
Schizoaffective Disorder
Schizophrenia
Selective Mutism
Suicidal Behaviors
Substance Abuse
Other
Family's Psychiatric History Additional information
Clinician Verified Psychiatric History

Query for past episode(s) of major depression
Have you ever had an episode of depressive symptoms (such as feeling very sad, empty, helpless, hopeless, etc.) that lasted 2 weeks or more and affected your abilities to go to work (or school), and/or your ability to care for yourself?

YesNo, there is no suggestive history of major depressive episodes
If yes, how many episodes across the lifespan
And when:
Additional Information
Query for a past history of persistent depression / dysthymia
Unlike episodic depression, dysthymia tends to linger for 2 years or more and can cause persistent sadness and dysphoria; sometimes affecting your appetite and/or sleep. These symptoms can also cause significant distress or impairment in your work/school and ability to socialize with others, but patients with persistent depression can generally continue to function at a suboptimal level at work or school.

YesNo, there is no suggestive history of persistent depression.
If Yes, how long has the depression persisted and when:
Additional Information
Query for a past episode(s) of mania or hypomania
Have you ever had a distinct episode, lasting at least a few days, where you experienced an abnormally elevated mood with feelings of euphoria, sometimes, this can also be associated with unrealistic grandiose thoughts, within a significant increase in your energy and activity level? Sometimes mixed into these high states there can be feelings of irritability. These mood states are quite different from one’s normal mood and are always observed by others.

If Yes, did these states cause marked impairment in social or occupational/academic functioning:ManiaHypomania, if these manic-type mood states were not severe enough to cause significant vocational, academic or social impairment.Drug induced mania: if any of these manic or hypomanic mood states are caused by medications or substances.No – if there was no history of mania or hypomania.
How many of these episodes have you had across the lifespan and when:
Additional Information
Query for a past history of panic disorder
Have you ever had an intense rush of panic when you suddenly felt very frightened or extremely anxious? Panic attacks typically cause the heart to race, shortness of breath, sometimes associated with a feeling that one is going to die or go crazy.

If Yes, when did these panic attacks occur when they were recurring frequently, how many were you having per month:Agoraphobia, did these panic attacks ever occur when you were using public transportation, or in open places such as a bridge or in an empty parking lot, or when in the back of a big store where it might be difficult to exit the store?No history suggestive of panic disorder.
Additional Information
Query for a history suggestive of social anxiety
Social anxiety, if social situations almost always provoked fear or anxiety. As a result, these situations were avoided. If patient has a history of social anxiety when did it peak:

YesNo history suggestive of past social anxiety.
Additional Information
Query for a history suggestive of generalized anxiety
Generalized anxiety, if there is a history of excessive anxiety and worry and/or nervousness, tension, and/or a feeling of near constant apprehension that has lasted for a period of 6 months. These feelings are generally omnipresent across a variety of settings (home, work, school, and social).

YesNo history suggestive of generalized anxiety disorder.
Additional information
Query for a history of OCD
OCD, if there has been a history of intrusive and unwanted recurrent and persistent thoughts, urges or images that are difficult to control or suppress; And these obsessions are followed by some repetitive behavior(s) either physically (e.g. hand washing) or mental acts (e.g. counting). These rituals must take up at least 1 hour per day and cause significant impairment in social, occupational or other areas of important function.

YesNo history suggestive of OCDObsessive thoughts related to a different diagnosisNo compulsions
Additional Information
Query for post-traumatic stress disorder

Assess if the patient has ever been exposed to a life-threatening situation, like a natural disaster, combat, caught in a burning home, etc. Also ask if the patient has a history of being physically, sexually and/or emotionally abused, or threatened with physical or sexual assault. Or if they have ever witnessed another person being assaulted or killed.
PTSD, if exposure to any of these events resulted in recurrent and intrusive distressing memories (when awake or asleep) of the traumatic event(s); and/or the patient has dissociative reactions (e.g. flashbacks) in which the patient feels or acts as if the traumatic event(s) were recurring. Lastly, marked physiological reactions to internal or external cues of these events.

YesNo history suggestive of PTSD.Symptoms endorsed for less than 30 days: Acute Stress Disorder
Additional Information
Query of a history of non-substance related psychotic disorders
Does the patient have a history (either reported by others, self or based on the evaluating clinician’s suspicion) of false beliefs based on incorrect inference about external reality that is firmly held despite what almost everyone else believes in that person’s culture of greater than 1 month. If yes, please query for the following:

Delusions of reference, beliefs that events, objects or other people in the patient’s immediate environment have a particular or unusual significance (e.g. the TV commercial is referencing the patient in a unique or individualistic manner).Persecutory delusions, a belief that an individual (or their family/group) is being or going to be attacked or is being persecuted or conspired against.Grandiose delusion, a belief that the patient has exaggerated or special, unique powers or knowledge or has a special relationship with a famous person. Erotomanic delusions also fall in this category in that a famous person is in love with the patient.Somatic delusion, a belief that the patient has something living inside them or some disturbance in body appearance or functioning. Note, body dysmorphic disorder can overlap or fall within this category.Delusions of guilt, jealousy and/or religious delusions.Thought or magical thinking related delusions such as the belief that one’s thoughts are being controlled, inserted and/or withdrawn or broadcasted so others can read their mind.
Does the patient have any history of hallucinations?

YesNo
If yes, please query for the following:

Auditory hallucinations, if the patient has a past history involving sound, typically voices, when fully awake and these events are heard either inside or outside of one’s head that are not heard by others.Other hallucinations, either in addition to auditory or independent from auditory hallucinations such as visual, tactile, somatic (e.g. a feeling of electricity going throughout the body), gustatory or olfactory. Please indicate the type if presentIf the patient has a history of delusions, hallucinations or you suspect some other type of behavioral disorder query for a history of catatonic behavior.Catatonia type behaviors, the patient has a past history of abulia (no or greatly diminished ability to initiate movement such as mutism), grimacing, odd posturing or mannerisms, stereotype (repetitive nongoal directed motor movements), echolalia, echopraxia, and/or waxy flexibility.Schizophrenia, if delusions, hallucinations, grossly disorganized and/or catatonic behaviors have been present for at least 6 months (or less if successfully treated) and have not occurred within a context of a mood disorder and the psychotic symptoms were not induced or related to the use of psychedelic substances. During this 6 months period, there has been a marked deterioration in one or more major areas of functioning such as self-care, work/school, and/or interpersonal. Please account for prodromal and residual phases within any past 6 month period. Symptoms and deficits in the prodromal/ residual phases can be less pronounced and disturbing then the active phase and can include only negative/abulic type deficits.Schizophreniform, if the psychotic symptoms/deficits described above have lasted less than 6 months.Schizoaffective disorder, criteria for Schizophrenia is met and there was an episodic of major depression and/or mania during the 6 month period.Brief psychotic disorder, if delusions, hallucinations and/or disorganized/catatonic behavior has been present for at least 1 day but less than 1 month and these symptoms/deficits were not related to any substance use.
Additional Information
Hematologic

No prior hematologic historyAnemiaBlood transfusionHodgkinsLeukemia acuteLeukemia chronicLeukopeniaLymphocytopeniaLymphomaPlatelet dysfunctionOther
Patient Medical History (Skip if this section has been completed in the Patient History Form)
None

Cancer
No prior cancer history
Breast Carcinoma
Colon Carcinoma
Esophageal Carcinoma
Hodgkin's Disease
Primary Liver Carcinoma
Lung Carcinoma
Melanoma
Ovarian Carcinoma
Pancreatic Carcinoma
Prostate Carcinoma
Other:

Cardiac
No prior cardiac history
Angina Pectoris
Arrhythmia
Arteriosclerotic Heart Disease
Atrial Fibrillation
CAD
Cardiac Arrest
Hypertension
Orthostatic Hypotension
CHF
Peripheral Vascular Disease
Bradycardia
MI
Respiratory Arrest
Syncope
Tachycardia
Other:

Dermatologic
No prior dermatologic history
Acne
Alopecia
Cellulitis
Dermatitis
Pressure sores
Psoriasis
Rosacea
Scabies
Sunburn
Warts
Other:

ENT Disorders
No prior ENT disorder
Myringitis
Vocal Cord Paralysis
Earache
Nasal Polyps
Vocal Cord Polyps
External Otitis
Otitis Media
Vocal Cord Nodules
Hearing loss
Otosclerosis
Tonsillitis
Herpes Zoster Oticus
Perichondritis
Labyrinthitis
Positional Vertigo
Laryngitis
Presbycusis
Mastoiditis
Rhinitis
Meniere’s Disease
Sinusitis
Other:

Hepatic and Biliary:
No prior hepatic and biliary history
Cirrhosis primary
Vascular lesions
Cholecystitis
Fatty Liver
Choledocholithiasis
Fibrosis
Cholelithiasis
Hepatitis
Cirrhosis alcohol
Hepatic Granulomas
Other:


Hematologic:
No prior hematologic history
Anemia
Blood transfusion
Leukemia chronic
Platelet dysfunction
Leukopenia
Hodgkins
Lymphocytopenia
Other


Immunodeficiencies
Oral Disorders

No prior oral disorderDysphagiaOropharyngeal basedEsophageal basedEdentulousGingivitisOther
Any other additional information

Patient Intake Form

I. Patient Information

II. Referral Information

III. History of Presenting Problems

IV. Medications

V. Treatments, Therapies, and Interventions

VI. Review of Neurodiagnostic Studies and Labs

VII. Neurodevelopmental, Neurological, Psychiatric and Medical History

VII. Social, Employment, and Educational History

Clinical Centers

Patient Services

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