Michael Ratener MD / Psychiatry

Pre-Intake History


If you've made an appointment to see me, please complete this form.

Providing answers to these basic questions before we meet will enable us to use the time we'll have to talk more personally. I'll be able to tailor my treatment suggestions to your particular needs, and you'll have more of a chance to bring up any concerns you may have. So please, if at all possible, send it in at least 24 hours before your appointment. I know that it will take quite a while to complete; if it's too long to finish at one sitting, you can submit an uncompleted form (using the button at the bottom of this page), and then return to answer the rest of the questions at another time. In that case, you can just fill in your name at the top, and then scroll down to the questions that you hadn't yet answered.

Note: this a secure form. All information is safely and very privately transmitted and stored.
Name:
Date of Birth:
Phones:
E-mail:
Address:
Message Preferences:
Emergency Contacts:
Occupation:
Referred By:
How would you describe whatís "normal" for you in terms of mood, energy, etc., when youíre not in the middle of an unusually stressful period?
Regarding the problem thatís leading you to seek an evaluation:
What are the current symptoms?
What was the approximate starting date, if that can be determined?
Did any obvious stresses, events, or changes precede the onset?
Were there any prior episodes that were similar to this one? If so, give some idea of the years they occurred, their duration, and their severity relative to the current episode.
In addition to the chief problem as above, have you had much difficulty with any of the following? If so, mention the frequency and severity. Fill in only the problems that you think may be significantly worse for you than for other people. You donít need to repeat the information about the main problem.
Depression
Anxiety
Substance Abuse
Eating Disorders
Other compulsive behaviors or obsessive thoughts
Suicidality
"Highs" in mood or energy not related to drug use. These might be mild, and might be high only relative to your usual mood Ė but would be distinctly elevated for you, and would not necessarily be due to an obviously exciting/happy situation
Difficulty maintaining attention at school or work. This would apply mostly to subjects or activities that didnít interest you.
Irritability or explosive anger
Problems with memory or concentration not obviously related to one of the above
Have you taken any antidepressants, tranquilizers, or sleeping pills? If so, please list past and present medicines, and whether the were helpful and/or had side effects.
Have you had any history of heart disease, high blood pressure, anemia, breathing difficulties, ulcers, or any other major illnesses? If so, are they under control now?
Are you on any medications now?
For women: have you had any problems with menstruation, childbirth, menopause?
Do you have any food or medicine allergies or sensitivities?
Do you get headaches (beyond occasional headaches that non-prescription medicines can treat).
Frequency
Severity
Do they ever occur on only one side at a time?
Areas of the scalp and neck affected.
Have you ever had your thyroid checked by blood tests? If so, do you know the results?
Have you ever had an EKG, and if so do you know the results?
Do you know any relatives who have had psychiatric or substance abuse problems, or (if not formally diagnosed) any of the emotional symptoms mentioned above?
Were there any events or situations in your childhood that you think I should know about (such as abuse, alcoholic parent, death of a parent, etc.)
How would you describe your self and your life as an adult, in terms of:
(even just a few words about these would be helpful)
Close relationships (marriage, family, friends)?
Stressfulness and/or satisfaction at work or school?
Finances
Spirituality
Other major life events/circumstances

If you've only completed part of the form, please, please, please, remember to return to complete the rest. It's really tremendously helpful.