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INITIAL INTAKE INFORMATION QUESTIONNAIRE
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Name: _______________________ Date of Birth: ______________

Date: ____________  Height ___ft__ in. Weight _______lbs.

 

Reason(s) for the consultation: (Circle all that apply)

ADHD · Alcohol · Anger · Anxiety · Apathy · Appetite · Attention · Avoidance · Behavioral ·Bodily_issues · Delusions ·  Depression ·  Dysfunctional · Fatigue · Fears · Grieving · Guilt · Hallucinations · Insomnia · Isolation · Libido · Negativism · Obsessions · Panic · Prescriptions · Restlessness · Substances · Suicidality · Suspiciousness · Worries · Other

 

Referred By: (Circle) Family · Friend · Colleague · Employer · Professional · Doctor · Other

 

Which of areas of your life are currently affected? (Circle all that apply)

Friendships · Peer_relationships · Romantic_relationships · Marriage · Family · Situation ·Employment · Financial · Personal_Loss · Interests · Hobbies · Physical_health · Self-care ·Eating_Habits · Sleeping_habits · Sexual_functioning · Concentration · Temperament ·Impulsivity · Legal_matters · Other

 

What types of interventions have been helpful to you? (Circle all that apply)

Exercise · Mindfulness · Self-help · Readings · Relaxation · Techniques · Counseling ·Couple_or_group_therapy · Psychotherapy · Behavioral_therapy · Self-help_groups ·Prescribed_Medications · Primary_Care_Provider · Psychiatrist · Recreational_substances ·Detox/Rehab_program(s) · Other

 

Which of these non-prescribed substances have you been using? (Circle all that apply)

Coffee · Nicotine_E-cigarettes · Nicotine_vaping · Alcohol · Sober · CBD-use · Marijuana ·Amphetamines · Cocaine · Hallucinogens · Narcotics · Inhalants · MDNA · Ecstasy ·Intravenous · Other

 

Currently prescribed medications for a mental health reason: (Circle all that apply)None · Antidepressant · Antianxiety · Stimulant · Antipsychotic · Pain_medication · OtherList of Medication(s) ________________________ Allergies Y/N (Specify)________Past Medication(s) Y/N (Specify)____________ Past Hospitalization(s) Y/N _______

 

Known history of medical or other conditions or prescribed medications?

Fevers · Covid-19 · Fatigue · Chronic · Pain · Migraines · Brain · Injury · Concussion ·Meningitis · Encephalitis · Seizures · Tumors · Cancer · Surgeries · Thyroid ·Endocrine_condition · Cardiac_condition · Arrhythmia · Heart_sounds ·Liver_disease · Kidney_disease · Menstrual_abnormalities · Contraception ·Bleeding_or_Clotting_disorders · Glaucoma · Asthma · Iron_deficiency ·Vitamin_D_deficiency · Vitamin_B-12_deficiency · Other_condition(s) ·Other_medication(s) (Specify)_____________________________

 

Prescribed medication(s) and OTC remedies: (Specify)___________________

Primary care provider? Practice: ____________________ Phone: _____________

 

What is your employment status? (Circle which applies)

Currently · Employed · Self_employed · Unemployed · Student · Homemaker ·Military_service · Injured · Disabled · Multiple · Employments · Satisfied · Dissatisfied ·Other (Specify)________ Position Title: ____________ For How Long?_______

 

What is your highest level of education achieved? (Circle all that apply)

High_school · Vocational · Undergraduate · Graduate · Post-graduate ·Currently_enrolled · High_Achiever · Average_Achiever · Underachiever Marital status: (Circle all that apply) Never_married · Married_once · Multiple_marriages ·Divorced · Widowed · Satisfied · Dissatisfied · Other (Specify)____________

 

Where and with whom do you reside in your household? (Circle all that apply)

Apartment · House · Alone · Partner · Roommates · Young_children · Adult_children ·Parent(s) · Other_family_member(s) · Pets · Plants · Other (Specify)_________________  

 

Where were you born? _____________ Where did you grow up? _________________

 

What is your family structure, situation and history? (Circle all that apply)

Single_parent · Parents_married · Parents_divorced · Parent(s)_alive ·Stepfamily · Siblings · Stepsiblings · Youngest · Oldest · Middle · Other (Specify)_______ Family Member with Medical Illness(es) N / Y (Specify)__________________________Family Member with Mental Illness(es) N / Y (Specify)___________________________

 

Early childhood or adolescent traumatic experiences? (Circle all that apply) Parental_death(s) · Sibling_death · Parental_divorce · Separation_from_parent(s) ·Multiple_family_relocations · Sibling_rivalry · Family_situation_difficulties · Other  (Specify)___________________________________

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Do you have goals for your treatment?

Short-term goals: (Specify)_________________________________________________

Long-term goals: (Specify)_________________________________________________  

 

Thank you utilizing my professional services.

Dr. Ronald Liteanu, M.D.

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