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Dr. Kantamneni
Dr. Patel
Gaelle Gounteni
Carla Odeniyi
Chloe Borrelli
Jessica Perez
Edward Hicks
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Adult Clinical Assessment
Step
1
of
9
11%
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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