Adult Clinical Information and History

Today's Date: *

Email Address *

Confirm Email *

First Name: *

Middle Name *

Last Name: *

Date of Birth: *

Street Address: *

Address Line 2:

City: *

State: *

Zip Code: *

Home Phone Number: *

Mobile Number:

Work Number:

Is it OK to leave message at: (Please Check all that apply)

Home

Mobile

Work

Marital Status: *

Emergency Contact: (Name and Phone Number) *

My Appointment is with: *

Date of Appointment: (if known) +

Primary Physician Name: *

Primary Physician Phone Number: *

Is it okay to send a consultation note to your PCP or other providers of care after your visit? Indicate "Yes" unless you would prefer privacy. *

Yes

No

Please provide the name and contact information for other clinicians involved in your care (i.e. other doctors, therapists, etc.) *

Who or how were you referred to Dr. Lea Lockwood? *

Brief description of the current situation and why you are seeking help at this time

Please explain the reason that you are seeking help at this time. *

Current Symptoms

Current Symptoms: *

Other current symptoms not listed:

Any recent life changes or other stressful events, including the death of a relative?

Past Medical History

PAST PSYCHIATRIC HISTORY: Please provide details regarding past psychiatric services including names of clinicians, locations and dates of treatment, etc.

PAST MEDICAL HISTORY: Please list any pertinent past medical history

PAST SURGICAL HISTORY: Please list any past surgeries/operations/medical hospitalizations

Allergies/Medication Intolerances:

Please indicate if you have had any of the following tests completed in the past:

Please provide any additional information regarding any of the items you marked above:

Current Medications

Please list all of the current medications which you take including the name, dose, and directions:

Previous Psychiatric Medications

Please provide detailed information about your past experiences with any of the medication listed above

Substance Use

ALCOHOL ABUSE HISTORY CURRENT

ALCOHOL ABUSE HISTORY PAST

DRUG USE CURRENT

DRUG USE PAST

TOBACCO USE CURRENT AND PAST

CAFFEINE USE CURRENT AND PAST

Substance Use Treatment History

AA/12-Step Groups

Substance Abuse Inpatient Treatment

Substance Abuse Outpatient Treatment

Substance Abuse Residential Treatment

Court-Ordered Treatment

Please provide details regarding any past substance use treatment history

Review of Systems

Please indicate if you have any problems/issues with the following

Please provide details on any of the items marked above

Family Psychiatric/Medical History

Below, please provide any information you have regarding any family history of psychiatric issues (i.e. depression, anxiety, bipolar disorder, substance abuse, schizophrenia, dementia, OCD, attention deficit disorder, suicide, etc)

Below, please list the major physical health issues of biological family members and their relationship to you.

Social History

Born in

and raised in

Name and ages of brothers/sisters:

Education (Highest grade, GED?, any college degrees and from where): *

Parents (ages, still alive, married/divorced/occupations):

Marriages/divorces (dates, etc): *

Children (names, ages): *

Military/Jobs (dates, where, company name, branch of military & reason for discharge, ect.): *

Legal issues: *

Please use the link below to attach a file to your questionnaire, if desired

Do you: *

Own

Rent

Live with Others

Addiction	Anger	Anxiety	Appetite Decreased
Appetite Increased	Compulsions	Concentration Impairment	Constipation
Depressed Mood	Destruction of property	Diarrhea	Dizziness
Excessive Sweating	Fatigue/Tiredness	Fear	Feelings of Guilt
Feelings of Hopelessness	Gambling Excessively	Hallucinations	Impaired Family Relationships
Impaired Productivity at Work/School	Impulsivity	Inability to Enjoy Activities	Indecisiveness
Irritability	Loneliness	Memory Impairment	Mood Swings
Nausea	Obsessive compulsive symptoms	Overuse/Misuse of alcohol	Overuse/Misuse of recreational drugs
Pain-Back	Pain-Gastrointestinal	Pain-General	Pain-Headache
Pain-Lower Extremities	Pain-Shoulder	Pain-Upper Extremities	Panic Attacks
Paranoid Thoughts	Racing Thoughts	Restlessness	Self harm (cutting, hitting, burning)
Sexual Difficulties	Shakiness/Tremulousness	Shopping/spending excessively	Sleep problems-difficulty falling asleep
Sleep problems- difficulty staying asleep	Sleep problems-sleep is non-restorative	Sleep problems-waking too early	Suicidal Thoughts
Tearfulness	Violence towards others	Weight Gain	Weight Loss
Other (list below)

Sleep Study	Psychological Testing
Neuropsychological Testing	Brain MRI or CT Scan
EEG	Thyroid Tests
Testosterone Level	Hormone Levels

adderall (amphetamine)	adderall xr (amphetamine)	ambien (zolpidem)	ambien cr (zolpidem)	aricept (donepezil)
ativan (lorazepam)	celexa (citalopram)	concerta (methylphenidate)	cymbalta (duloxetine)	depakene (valproic acid)
depakote (divalproex sodium)	depakote er (divalproex sodium)	desyrel (trazodone)	effexor (venlafaxine)	effexor xr (venlafaxine)
elavil (amitrityline)	emsam (selegiline)	eskalith (lithium)	focalin (dexmethylpheidate)	focalin xr (dexmethylphenidate)
geogon (ziprasidone)	haldol (haloperidol)	halcion (trazolam)	invega (paliperdone)	klonopin (clonzepam)
lamictal (lamotrigine)	lexapro (escitalopram)	lithium (lithium)	lithobid (lithium)	lunesta (eszopiclone)
luvox (fluvoxamine)	luvox cr (fluvoxamine)	nardil (phenzelzine)	norpramin (desipramine)	pamelor (nortriptyline)
parnate (tranycypromine)	paxil (paroxetine)	paxil cr (paroxetine)	pristiq (desvenlafaxine)	prozac (fluoxetine)
remeron (mirtazapine)	restoril (temazepam)	risperdal (risperidone)	rozerem (ramleteon)	seroquel (quetiapine)
sonata (zaleplon)	strattera (atomoxetine)	tegretol (carbamazepine)	tofranil (imipramine)	valium (diazepam)
vivactil (protriptyline)	vyvanse (amphetamine)	wellbturin xl (bupropion)	wellbutrin (bupropion)	wellbutrin sr (bupropion)
xanax (alprazolam)	xyrem (sodium oxybate)	zoloft (sertraline)	zyprexa (olanzapine)	Others Others

Allergies	Bleeding	Bone	Dementia
Digestive system	Endocrine system	Eyes	Hearing
Heart of blood vessels	Infections	Inflammation	Joints
Kidney or Bladder Disease	Liver Disease	Lungs or sinuses	Migraines
Mouth	Muscles	Neurological system	Night mares or waking up
Pain and location	Passing out	Prostate trouble	Reproductive system or menstrual cycles
Seizure Disorder	Sexual Problems	Skin	Sleep walking
Snoring	Stomach	Stroke	Talking
Teeth	Throat	Tics