Geriatric Psychiatry Intake Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Address
Emergency Contact
Name
Phone Number
Relationship
Primary Care Physician
Name
Phone Number
Reason for Visit
Please describe the reason for today's visit
Current Symptoms
List current symptoms/concerns
Medical History
Past medical conditions and hospitalizations
Medications
Current medications (include dosage and frequency)
Psychiatric History
Previous psychiatric diagnoses/treatments
Family Psychiatric History
Any family history of psychiatric or neurologic illness
Functional Status
Describe ability to perform daily activities (ADLs/IADLs)
Substance Use
History of tobacco, alcohol, or other substance use
Additional Notes