Ourservices

Jerzy Grzebieluch MD
Certified by American Board of Psychiatry and Neurology

FIRST NAME

LAST NAME INITIAL

Date and time of your appointment

DOB MM/DD/YYYY

REASON FOR THE
CONSULTATION

Have you been having problems with any of the following symptoms?

1. Have you felt low in spirits or sad ?                                                     NO

2. Have you lost interest in your daily activities ?                                  NO

3. Have you felt lacking in energy and strength ?                                  NO

4. Have you felt less self-confident ?                                                       NO

5. Have you had a bad conscience or feelings of guilt ?                       NO

6. Have you had difficulty with concentrating ?                                      NO

7. Have you felt restless or slowed down ?                                            NO

8. Have you had problems with sleeping too much or not sleeping ? NO

9. Have you had problems with increased or decreased appetite ?   NO

10. Have you felt that life was not worth living ?                                   NO

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

1. Have there been times lasting for at least 4 days when you felt
very high or irritable and this felt different than your normal self ?            NO

2. Were there nights you got less sleep than usual and found you
didn’t really miss it ?                                                                                           NO

3. Did you feel pressure to talk constantly ?                                                    NO

4. Did you feel like your thoughts were racing through
your mind ?                                                                                                           NO

5. Were there times when you were so
energized or agitated you couldn’t sit still?                                                     NO

6. Did you find you were easily distracted?                                                       NO

7. Did you do anything that was unusual for you or that other people
might think was excessive, foolish or risky?                                                   NO

YES

YES

YES

YES

YES

YES

YES

1. Have you experienced unexpected periods of sudden rush of intense fear       NO
or discomfort that come for no apparent reason?

2. Do you have strong fears of being in certain places or situations ?                       NO

3. Do you have strong fears of public speaking or other social situations?              NO

4. Have you been worrying excessively about a number of things in
your daily life?                                                                                                                     NO

5. Do you experience recurrent thoughts or impulses that seem inappropriate
or do not make sense, but they keep repeating and are difficult to get out of
your mind ?                                                                                                                          NO

6. Do you have to do something over and over that you can't resist when
you try ( washing, counting, checking ..) ?                                                                     NO

YES

YES

YES

YES

YES

YES

1. Do you often make careless mistakes when at work or doing chores                  NO
around the house ?

2. Do you frequently have difficulty focusing on one thing for a long time ?           NO

3. Do others say that you don't listen when they talk to you ?                                    NO

4. Do you have difficulty finishing things ?                                                                   NO

5. Is it hard for you to be organized ?                                                                            NO

6. Do you lose things ?                                                                                                     NO

7. Are you very forgetful ?                                                                                               NO

8. Is it hard for you to sit still ?                                                                                        NO

9. Are you often on the go, doing something ?                                                           NO

10. Do you often have difficulty awaiting turn ?                                                           NO

11. Do others get angry because you interrupt them while they are talking ?         NO

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

Have you ever taken any of the following medications ?

NAME

YES

YOUR RESPONSE, SIDE EFFECTS

Buproprion ( Wellbutrin )

Mirtazapine ( Remeron)

Citaprolam ( Celexa)

Escitaprolam ( Lexapro)

Fluoxetine ( Prozac)

Sertaline ( Zoloft)

Paroxetine ( Paxil)

Fluvoxamine ( Luvox)

Venlafaxine ( Effexor)

Duloxetine ( Cymbalta)

Lithium

Valproate ( Depakote)

Lamotrigine ( Lamictal)

Alprazolam ( Xanax)

Lorazepam ( Ativan)

Clonazepam ( Klonapin)

Ambien

Lunesta

Risperidone ( Risperdal)

Olanzapine ( Zyprexa)

Quetiapine ( Seroquel)

Aripiprazole ( Abilify)

Ziprasidone ( Geodon)

Ritalin

Concerta

Metadate CD

Adderall

Strattera

Please, check if any of the following family members has a history of
following problems?

MOTHER

Father

Sister
(s)

Brother(s)

Daughter
(s)

Son
(s)

Maternal
Grand
mother

Maternal
Grand
father

Paternal
grand
mother

Paternal
grand
father

Any
Blood
relative

Anxiety

Depression

Bipolar
(Manic)

Alcohol
Abuse

Drug
Abuse

Schizophrenia

ADHD/
ADD

Suicidal
Behavior

Psychiatric
Hospitalization

With whom did you live between the age 0 -5 ?

With whom did you live between the age 5-10 ?

With whom did you live between the age 10-15 ?

How do you describe the relationship with
your biological mother ?

How do you describe the relationship with
your biological father ?

Did you see violence in your family ? NO

IF,YES

Did anyone sexually abuse you? NO

IF,YES

How far did you go in school ?

What were your grades ?

What kind of work do you do ?

What other jobs have you had ?

What's was the longest job you have ever had ?

What is your current marital status ?

Have you ever been married ?

How many times you were married ?

How would you describe your marriage(s) ?

If DIVORCED Why did you divorce ?

Do you have any children ? What are their ages and sexes ?

With whom do you currently live ?

Have you been suffering from any of the following medical problems ?

EYEs/EARS/NOS
E/Mouth/
THROAT

Glaucoma

NO

YES

Cataract


NO

YES

Other problems with hearing/nose/mouth/throat

NO

YES

HEART and
Blood Vessels

Coronary heart disease(artherosclerosis, heart
attack)

NO

YES

Hypertension (High Blood Pressure)


NO

YES

Congestive Heart Failure


NO

YES

Heart Arrhythmia - Irregular heart beat


NO

YES