Name:	Date:

Dear Patient:

Your appointment today is for 20 - 30 minutes. This is not a lot of time. Please note that appointments that run longer than 30 minutes will be charged the 30 – 45 minute appointment rate. To save time and money, please complete this form.

INSURANCE CHANGE: Has your insurance changed since your last appointment here? □ No	□ Yes: ____________

MEDICAL PROBLEMS

Since your last appointment with your provider (i.e. Dr. Massoumi, Marisa, Dan, Alyse or Sam) have you experienced a NEW ONSET or WORSENING of any of the problems listed below? (Please circle or check “yes/no” as appropriate)

BODILY SYSTEM	PROBLEMS (please circle)	Yes	No	Please Explain
Weight	Weight gain. Weight loss.
Eyes	Blurry or worsening vision.
Ears/Nose/Mouth/ Throat	Throat tightening.
Cardiovascular	Increased blood pressure. Chest pain.
Respiratory	Difficulty breathing. Shortness of breath
Gastrointestinal	Nausea. Vomiting. Constipation. Diarrhea
Genitourinary	Difficulty urinating
Muscular	Muscle twitches. Muscle tightness. Muscle spasms
Integumentary	Skin rashes. Hives. Itchy skin. Psoriasis. Eczema. Acne
Neurological	Headaches. Dizziness. Lightheadedness
Endocrine (Thyroid)	Feeling hotter or colder than those around you.
Endocrine (Females Only)	Change in menstrual cycle
Hematologic/Lymphatic	Easy bleeding or bruising. Swollen legs
Allergies/Immune	Recent cold, sinus infection, or other recent illness.

Do you have paperwork (e.g. forms, applications, letters) for your provider to complete for you today? □ No	□ Yes (please explain): ________________________________________

On a scale of 1 to 10 (10 being the happiest) how would you rate your mood:

TODAY?

1	2	3	4	5	6	7	8	9	10

IN THE LAST WEEK? (Circle the average or the range)

1	2	3	4	5	6	7	8	9	10

At WORST in the past two weeks?

1	2	3	4	5	6	7	8	9	10

In the past few weeks, have you had any thoughts of wanting to end your life? □ No	□ Yes

How is your sleep?	□ Good	□ Variable	□ Poor

In the space below, write the TWO MOST IMPORTANT ISSUES (e.g. questions, problems, or symptoms) that you want to be sure to discuss with your provider today. (Questions not listed here might not get answered today!)

□ None	1) ____________________________	2) ____________________________________

Many people forget to take their medication(s) and/or supplement(s). What percentage of the time do you successfully remember to take your:

Medications? ________________	Supplements? ____________________

When you are done with this form, please alert the front desk. Thanks!!

(This page for doctor use only)

Orientation: A&OX3 Other____________

Appearance & Attitude: Wnl Other____________

Speech:	Fluent Slow Rapid Soft Loud Pressured Talkative Slurred Stuttering

Motor:	Normal Restless Slowed/Decr Tremors Shuffling gait or EPS Wheelchair-bound

Affect: Appropriate Labile Constricted Flat Full

Mood: Euthymic Depressed Anxious Angry/Irritable Euphoric Crying

Thought Process: Organized Circumstantial Tangential Loose Associations

Thought Content: Appropriate Delusional Concrete	Poverty

Perceptual Disturbance: None Auditory Visual

Attention/Concentration: Intact Impaired Deferred to Psychometric Measures

Suicidal/Homicidal Ideation: None Ideation Plan Intent

Insight/Judgement: Good Fair Poor

Fund of Knowledge: Intact Inadequate