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Henry Elder MD, Psychiatry |
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MAIN PROBLEM -- How and when it started
The main symptoms or problems then and NOW
Anything going on at that time which may have been related
What has happened since it started
Any clearly related situations now
PSYCHIATRIC/COUNSELING HISTORY What type, if you know, you’ve had so far
Who you saw (by name, if you remember) phones, faxes and addresses, if available
How long you saw this person
Past Psychiatric Medications: DOSAGE (MG) and HOW MANY? for HOW LONG (a few days, weeks, months?)
what it did that was bad, if anything what it did that was good, if anything
Current Medications: Dose, how many, how long:
side effects benefits concerns, if any
Suicide attempts: How many, what years, what methods. Thoughts about that currently? Plans?
PAST MEDICAL HISTORY any ongoing conditions and their treatment
Names and fax numbers of medical care providers
for women, any chance you could be pregnant now? how do you avoid pregnancy, if sexually active?
current medications not already named
herbal medications, please list name and dose
last time you had a blood test (send or bring your results if possible)
ALCOHOL AND SUBSTANCE USE How much alcohol do you drink? (drinks/week, on average) How many ounces, what kind?
Has this ever been a problem for you?
Are there other street drugs do you currently use?
How much per week?
FAMILY HISTORY For your generation, and two before you. Anxiety (who, what diagnosis, how treated?) Depression losing contact with reality suicidal behavior psychiatric hospitalization or seeing a psychiatrist. . SOCIAL HISTORY Relevant details of your past or current situation not already described in the "story" of your symptoms. What was discipline was like in your household when you were growing up, any physical or sexual abuse you experienced at any age?
are you being hit or abused in some way now
who do you live with now
what are you doing for income now
PLEASE CONSIDER COPYING , COMPLETING, AND SENDING RELEASE OF INFORMATION TO RELEVANT PROVIDERS OF CARE BEFORE THE MEETING. Also, see “SYMPTOMS” Anything else important?
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Sending Information in Advance Preparing information in advance can save us a lot of time -- and your money. For example, if you're seeing me for a consultation, we can spend more of that time talking about treatment options if the history of your symptoms and your previous treatment is already prepared. Otherwise usually we'll spend the first visit gathering the information below; and then I'll have you come back in a week, to continue the process. At that point we'll start talking about treatment options. So, you might save as much as a week's time by sending information in advance. The list below looks pretty huge. But organizing yourself and your information in advance will almost certainly produce a more satisfying experience. Best result for my organization and documentation is to send by email. You can print, complete, and send it by fax, or by “snail mail”, or just bring it in with you, in that order of helpfulness. Details you get by asking relatives or former doctors are great. The most important questions are in bold print. To send by email, click “File”, “Send e-mail” , then “Page”, then edit on your email program and send to tokdoc1@comcast.net Do the same with the “Symptoms” pages. If that doesn’t work, try printing and mailing the completed questionnaire. |
