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Adult Clinical Assessment

Step 1 of 9

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First Name(Required)

Last Name(Required)

Email(Required)

DOB

Age

Current Date(Required)

Current Time(Required)

Gender

Male

Female

Nonconforming

Preferred pronouns

Marital status

Married

Separated

Divorced

Single

Widowed

Number of Children, if applicable

Lives with

Roomates

Partner

Partner & Children

Multi-generational

Alone

Do you feel safe in your home?

Yes

No

If no, please explain

Current Profession

Employer

Is this visit work related?

Yes

No

What brings you into our office today?

What are your treatment goals and expectations?

If you were referred by a treatment provider, please write their first and last name below

May we contact them to thank them for the referral?

Yes

No

Review of Current Symptoms

(please check all that apply in the last 6 months)

Sleep

Awakens screaming/crying

Awakens at night

Difficulty falling asleep

Early waking

Insomnia

Sleeping less than normal

Daytime sleepiness

Jerking during sleep

Nightmares

Sleeping more than normal

Difficulty waking up

Physical

Red fingers/toes

Webbed toes

Red ears

Double jointed

High arched/Cleft palate

Lymph nodes in neck always swollen

Head warm/always sweaty

Abnormal fatigue

Cold all over/hands, feet

Cold intolerance

Hands/feet very sweaty

Night sweats

Odd smelling sweat, urine

Skin

Very Pale

Very sensitive to bug bites

Stretch marks

Blotchy skin

Dry/brittle hair and scalp

Nails frayed, pitted, brittle or soft

Easily bruised

White spots/lines in nails

Acne

Itchy Ears or roof of mouth/throat

Fungus on fingers/toenails

Dandruff

Oily skin/Dry skin

Patchy dullness

Seborrhea on face

Thick calluses

Smelly feet

Itchy skin (for no known reason)

Mood

Persistent sadness

Excessive worry

Excessive tearfulness

Paranoia

Low frustration tolerance

Confusion

Uninterested

Excessive showering/bathing/hand washing

Suicidal/Homicidal thoughts/actions

Desire to be alone

Elevated Mood

Hyperactivity

Trying to control others

Verbal aggression

Physical aggression

Decrease in hygiene

Behavior(Required)

Self-mutilation (cut/scratch/head bang/etc)

Avoiding responsibilities

Excessive spending

Pacing or inability to sit still

Uncharacteristic hypersexuality

Excessive masturbation

Excessive electronic use

Rapid/excessive speech

Staring off

Aggression towards animal

None of these ppply

Eating/Digestion

Excessive thirst

Excessive carbohydrates

Sugar cravings

Eat out of the home more than twice a week

Dairy intolerance

Gluten allergy/sensitivity

Gas/bloating

Abdominal pain

Reflux

Other

Please list any other abnormal or excessive symptoms

(from the last six months)

Testing History

Have you ever had genetic testing?

Yes

No

If yes, what were the results? Were you found to be a carrier of any illness or mutation?

Have you ever completed psychological testing?

Yes

No

If yes, when and what were the results?

Have you ever had a CT/MRI/PET scan of your brain or abdomen?

Yes

No

If yes, why, when and what were the results?

Have you ever had allergy testing?(Required)

Yes

No

If yes, what were the results?

When was your last physical exam?

Was bloodwork done?

Yes

No

Who is your Primary Care Physician?(Required)

Physician Phone Number

Physician Address

May we contact them for a copy of your labs?

Yes

No

Family Medical History

Please check applicable family member(s) for each illness

Sleep issues

Snoring, sleep apnea, insomnia, sleep walking, narcolepsy

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Developmental Disorders

Milestone delays, low IQ, Autism, Pervasive Developmental Disorder (PDD)

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Neurological Disorders

Seizures, migraine headaches, chronic headaches, Tics, Cerebral Palsy, PANDAS/PANS

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Infectious Disorders

Recurrent strep throat/ear infections/other

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Learning/Attention Disorders

Learning disability, Dyslexia, Dysgraphia, Dyscalculia, ADD/ADHD

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Gastrointestinal Disorders

Chronic diarrhea, chronic constipation, reflux, food intolerance, IBS, ulcers, Crohn’s, Celiac disease

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Inflammatory Disorders

Allergies, asthma, psoriasis, Hashimoto’s thyroiditis, Lupus, Rheumatoid Arthritis, autoimmune disorder

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Endocrine Disorders

Hypothyroidism, Hyperthyroidism, Cushing’s Disease, Adrenal insufficiency, Gigantism, early puberty

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Reproductive Issues-Women

PCOS, Endometriosis, Uterine Fibroids, gynecological cancer, Interstitial Cystitis, infertility

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Reproductive Issues-Men

Klinefelter Syndrome, prostate cancer, testicular issues

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Blood/Vascular Disorders

Anemia, Sickle-Cell Anemia, blood clots, hypertension

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Mood Disorders

Depression, Bipolar Disorders, Seasonal Affective Disorder, other

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Personality Disorders

Narcissism, Borderline, Histrionic, Avoidant, Dependent, other

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Psychotic Disorders

Schizophrenia, Delusional Disorder, Psychotic Disorder, Schizoaffective Disorder, Schizophreniform Disorder

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Eating Disorders

Anorexia Nervosa, Bulimia, Binge Eating Disorder, Night Eating Syndrome, Avoidant Restrictive Food Intake Disorder, other

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Anxiety Disorders

Generalized anxiety, panic disorders, OCD, phobias, social anxiety, selective mutism

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Trauma-related Disorders

Post-traumatic Stress Disorder, Adjustment Disorder, Reactive Attachment Disorder, other

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Substance Use Disorders

Alcohol, cannabis, opioids, hallucinogens, stimulants, sedatives, inhalants, other

Mom

Dad

Sibling

Mom's parents

Dad's parents

Mom's siblings

Dad's siblings

Maternal cousin

Paternal cousin

Medical History

Mother's age at birth

Father's age at birth

Number of pregnancies

Was there regular prenatal care?

No

Yes

If yes, please explain

Was your mother exposed to mercury or other toxins while pregnant?

No

Yes

If yes, please explain:

Was Mother given RhoGAM injection?

Yes

No

Did your mother receive vaccines when pregnant?

Flu

T-dap

Other

Other vaccine(s)(Required)

Did your mother experience any pregnancy related issues?

(please check all that apply)

Bacterial illness (UTI, GBS+)

Bleeding/Spotting

Eclampsia/ HELLP syndrome

Gestational diabetes

Hypertension

Pre-eclampsia

Preterm labor

Recurrent yeast infections

Viral illnesses

Vomiting requiring medication/hospitalization

Amniocentesis

Lived in home built before 1978

Did mother take any medications or supplements during pregnancy?

Yes

No

If yes, please list the medications

IF IN UTERO AND INFANCY HISTORY IS UNKNOWN, PLEASE CHECK HERE

Unknown

Gestational age at birth

(in weeks)

Birth weight

Birth length

Delivery method

Vaginal

Cesarean

Forceps or suction used?

Yes

No

Where you admitted to the NICU?

Yes

No

Length of stay

Did you have physical contact ("skin to skin") time with parents?

Yes

No

Infancy Dietary History

Breast fed

Formula

Infantile eczema

Special diet/restrictions first year

Colic

Reflux

Milk/Formula intolerance

How long breast fed?

What type of formula?

What special diet/restrictions?

Adult Dietary History

How would you describe your dietary habits? Check all that apply.

Balanced/healthy

Carbohydrate heavy

Vegetarian

Excessive sugar intake

Alternative dairy source

Fast food more than once a week

Excessive Caffeine intake

Pescatarian

Kosher

Gluten free

Halal

Keto

Do you have food allergies or sensitivities?

Check all that apply.

Wheat allergy

Wheat sensitivity

Dairy allergy

Dairy sensitivity

Nut allergy

Fruit allergy

Other

Other food allergy/sensitivity

Do you have any food related symptoms that you experience on a regular basis?

Check all that apply.

Stomach aches

Burping

Gas

Bloating

Fatigue

Flushing

Itching

Hyperactivity

Other

Other food related symptoms

Has anyone ever expressed concern about your eating habits or diet?

No

Yes

If so, please explain

Do you ever feel guilty after eating?

Yes

No

Do you feel out of control when eating?

Yes

No

Do you hide food consumption from your loved ones?

Yes

No

Could you be pregnant?

Yes

No

Patient Medical History

Sleep Issues

Insomnia, sleep walking, narcolepsy, sleep talking, sleep apnea

Developmental Disorders

Milestone delays, low IQ, Autism, Pervasive Developmental Disorder (PDD)

Neurological Disorders

Seizures, migraine headaches, chronic headaches, Tics, Cerebral Palsy, PANDAS/PANS

Infectious Disorders

Recurrent strep throat, ear infections, sinus infections, other?

Learning/Attention Disorders

Learning disability, Dyslexia, Dysgraphia, Dyscalculia, ADD/ADHD

Gastrointestinal Disorders

Chronic diarrhea, chronic constipation, reflux, food intolerance, Celiac disease, IBS, ulcers, Chron’s/Colitis

Inflammatory Disorders

Allergies, asthma, psoriasis, Hashimoto’s thyroiditis, Lupus, Rheumatoid Arthritis, autoimmune disorder

Endocrine Disorders

Hypothyroidism, Hyperthyroidism, Cushing’s Disease, Adrenal insufficiency, Gigantism, early puberty

Substance Use

Alcohol use, Cocaine, Ecstasy, MDMA, Opiods, Synthetic drugs, marijuana, stimulants, inhalants, other?

Women

What age did menstruation begin? Are periods normal? Infertility issues? Other?

Men

Klinefelter Syndrome, testicular issues, erectile disfunction? Other?

Do you have any drug allergies?

If so, please explain.

Please list all medications/supplements you are CURRENTLY taking

Name of medication

Strength

Times per day

Name of medication

Strength

Times per day

Name of medication

Strength

Times per day

Name of medication

Strength

Times per day

Name of medication

Strength

Times per day

Name of medication

Strength

Times per day

Please check below if you are not currently taking medications

None

Please list any medications/supplements you have tried related to mental health.

Name of medication

Reason discontinued

Name of medication

Reason discontinued

Name of medication

Reason discontinued

Name of medication

Reason discontinued

Name of medication

Reason discontinued

Name of medication

Reason discontinued

Please check below if you have not tried any medications/supplements

None

Have you had any surgeries, inpatient hospital stays, or other significant medical history?

Please explain

Mental Health History

Have you ever self-harmed?(Required)

Yes

No

If yes, please explain

Have you ever attempted suicide?(Required)

Yes

No

If yes, please explain

What is the most negative thought you've had in the last two weeks?

Do you have a regular therapist?

Yes

No

If yes, who?

If yes, who?

If so, what is the reason you are establishing a relationship with a new psychiatrist?

Have you ever a psychiatric hospitalization? Why? When?

Have you seen a psychiatrist before?

Yes

No

Do you have a history of substance abuse?

Yes

No

If yes, please explain

Trauma Assessment

Have you ever been exposed to or the victim of:

(check all that apply)

Household violence

Physical abuse

Emotional/verbal abuse

Sexual abuse

Neglect

Loss of parent or sibling

Exploitation

Pornography

Bullying

Addiction in a parent

Other

If there is anything else you would like our providers to know, please write it in the space below.

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Contact Us

770.858.5377 e-fax: 770-874-3310

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Location

4125 Atlanta Road SE
Ste #120
Smyrna, GA 30080

Hours

Monday-Thursday
9am-5pm
Friday
9am-3pm

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770.858.5377

About
- Our Practice
- Philosophy
Approaches
Learn
Current Patients
New Patients
Contact