Suicide is a serious complication of psychiatric conditions and can be a psychiatric emergency.  If you are having serious
thoughts of hurting yourself or others at this time and have developed either a plan or intent to do so you should go to the
nearest emergency room or dial 911.


Notice:  The first session with Dr. Grace is a consultation only.  You will not be
considered a patient of this office and Dr. Grace will not be considered to be your
treating physician until both you and he agree after your first session together that there
is some benefit to be gained from working together. Therefore, do not rely on Dr. Grace
to refill prescriptions on the date of your first appointment.  If you do not enter into a
doctor-patient relationship after the consultation, he will not do so.

Name:

Contact Number:

Primary Insurance:

Secondary and Tertiary Insurances:


Why are you coming to see John W. Grace M.D., P.A. ? What is your chief complaint?


Who referred you to John W. Grace M.D., P.A.?  


Stressors:

 Are there any significant stressors in your life that have recently worsened?  (Financial problems, relationship difficulties,
Legal Problems, etc.  Please be specific.)



Suicidal and Homicidal Thoughts

When was the last time you thought seriously of hurting someone else or yourself?


Do you have a plan in place to hurt yourself or someone else?


Do you have access to weapons or pills?


Do you have a support system to talk to?


Is there a family history of suicide or homicide?


Do you abuse alcohol or drugs?


Is there any changes in your life that make suicide more reasonable option?  



PSYCHIATRIC SYMPTOMS

Have you ever had a period of pronounced depression lasting more than two weeks?


Have you ever had a period of elevated or irritable mood that lasted more than 3-4 days?  (This would be a mood so
elevated or high that people noticed a distinct change in you.)



Have you ever had a period where you needed very little sleep?  (You felt rested on a few hours)



Have you ever had a life threatening experience you dream about or relive in some way?



Have you ever had intrusive thoughts into your head that you can't seem to get out?  



Have you ever had any recurrent behavior that seems excessive or burdensome?  (Washing your hands, counting,
checking things, rituals, magic numbers)


Have you ever had disturbances in reality?  (Hearing voices, unbelievable beliefs)



Are you having any significant stressors right now?  What are they?  (Money, Relationship, Housing, be specific)



Psychiatric History:

Have you ever had problems with previous mental health providers?  Describe when and in what capacity.  



When have you received treatment for psychiatric symptoms?




Who provided this treatment and how long did you see them for?  



What was the treatment?  (Medication, Therapy, Hospitalizations).  If it was therapy. What kinds of things did you talk
about (Thoughts, Actions, Past history).



How effective were these treatment?  (Rate each one 0-100%)



What were the side effects of each treatment?  



How compliant were you with the treatments?  Be honest.  Most people are about 60-70% compliant with everything their
doctor recommend.
Please list other information about your treatment with psychiatrists:



Psychological History:

What are some of the values that you took from your childhood and where did they come from?  (Examples: Honesty is
very important.  Family means everything.  You are only as good as your word.  You need an education to amount to
anything.)  My father was like that.  My uncle was honest and that inspired me.  







What religions have influenced who you are?  How were you exposed to them?  





What do you do when you are faced with stressful situations?  Was there anyone who you knew growing up who used a
similar technique of dealing with stress?  For example: “I clam up.  I keep to myself.  I lose my temper.  I drink.”  “My
mother used to act really tense when stressed.”  





How much control do you feel you have in your life?  How much control do you feel that you need?  




How responsible do you feel for others around you?  For tasks at work?  Are you the type of person that everybody leans
on?  





How good is your self esteem?  Has it always been that way?  What were some things that affected it?




Substance Use History:

Have you ever had a significant impact on your life from alcohol or drugs?
Which ones?



How much do you drink on average?
How often do you drink on average?

For drugs and alcohol that have impacted your life when was the first use of each?  When did they affect your life?  Have
you had any periods of abstinence.  If so, when?


Medical History:

Name and Phone Number of current primary care Dr.  



Medical Problems and when they occurred.  (For example Thyroid Cancer 1988-present)



Current Medications (Dosage, How long you have been on, For What)





Allergies:(To What and What happened)




Family Psychiatric and Medical History:

Mother, Father, Aunts, Uncles, Cousins (What were they like even if not formally diagnosed).  Cancers.  Migraines.  
Substance Use?





Social History Questionnaire:  

Where were you born?


How many brothers and sisters? (Names and Ages)


What was your childhood like?  Were you abused physically, sexually or emotionally?



How were you punished as a child?  



What did parents do?



How far did you go in school?


What were you like in grade school?  (Popular, Teased, Social, Outgoing, etc)


What were you like in high school?  (Popular, Teased, Social, Outgoing, etc)




Sexual History:

When were you first exposed to sexual activity?   



Have there been problems with sex in the past (fear, pain, lack of interest).  Please describe in detail.  



What jobs have you had in the past and for how long?  Any problems?  When was the last time worked?



Military History:  List any.




Legal History: List any.  




Relationship History:

When was your first significant relationship?




How long did it last?  




What were the good things about it?




What were the bad things about?  




What were the things that you would change about yourself in it?




Was there any patterns from either earlier or later relationships?  For example, “I always found myself being ordered
around like I was a child.”  




What is you current living situation?  Who do you live with? How do you support yourself?  How long have you been in this
situation?  What is your monthly income?  What are your monthly bills?  Is debt a significant problem as well?





Review of Systems:

Please let us know if you have any problems with the following systems either long term or short term.  Read these
carefully!  Sometimes medical conditions can appear psychiatric.  Describe in detail in space provided?  

General Health:  Recent Weight Loss or Weight Gain.  Fever.  Fatigue.  





Skin:  Have there been any changes in your skin?  Your nails?  Open sores or rashes?  Itching?  Have there been any
lumps or moles that are new or changed?  Any changes in the color of your skin?  




Head:  Have you had any headaches?  Or Head Trauma?  Or Seizures?  Describe.  





Eyes:  History of Glaucoma?  Difficulty with your vision?  Flashing Lights?  Hallucinations?  Glasses?




Ears:  Do you have any difficulties with hearing?  Ringing in your ears?  Sense of the room spinning?  Ear pain?




Nose and Sinuses:  Do you have a history or current stuffy or runny nose?  Any nosebleeds?  




Mouth, Throat and Neck:  Any bleeding or soreness in your mouth or tongue?  Any sore throats or hoarseness?  Any
swollen glands?




Breasts:  Any lumps or nodules in breasts?  Any discharge from the breasts?  




Chest:  Any chest pains?  Feeling of your heart beating too fast?  Shortness of breath?  High blood pressure or history of
heart problems?  Any wheezing?  Swelling in the feat?  Or coughs?  Bloody or otherwise?




Gastrointestinal Tract:  Have you had any problem swallowing?  Any indigestion or heartburn?  Excessive Gas?  
Abdominal pain?  Nausea and vomiting?  Diarrhea?  Constipation?  Increase or decreased appetite?  Changes in your
stool?  




Urinary Problems:  Increased or Decreased Urination?  Problems urinating?  Change in color or smell or urine?  Change
in frequency of urine?  Urinating at night?  Drinking a lot?  Incontinence?  




If you are female, do you menstruate regularly?  Have you had changes in periods?  Their Intensity or duration?  Have
you had any vaginal discharge or sexual problems?  Have you ever been pregnant?  Is there a chance your pregnant?




If you are a male have you had any sexual difficulties?  Impotence?  Erection Problems?  Discharge from penis?  




Musculoskeletal:  Pain in Joints?  In arms or legs?  Swelling of feet or legs?  Do you fingers change color in the cold?  Is
it one or many joints?  Which ones?  How long?  Back Pain?




Nervous System:  History of fainting or loss of consciousness?  Seizures?  Tremors?  Weakness or unusual
sensations?  Tremors?




Hematological:  Easy bruising or bleeding?  Where, how intense?




Endocrine:  Do you have intolerance of heat or cold?  Do you eat or drink more than you have in the past?  




Have you ever had transient loss of consciousness, blanking out, where you didn't remember where you were or how you
got there?  How often do these episodes last?  



Have you ever traveled out of the country?  Puerto Rico? Etc?



Have you ever been in other parts of the country?  The Midwest?  The northeast?  If so have you ever been bitten by a
tick that you know of?  



Have you ever lost movement or sensation in any part of your body?  Where?  Describe it?  



Do you have any risk factors for HIV, Hepatitis C, or Syphilis?  Unprotected sex?  Blood Transfusions?  IV Drug use in the
past?  Have you been tested for these conditions?  



Do have any arthritis that comes and goes?  



Do you ever have flushing that comes and goes?