Kemet Health
I’m seeking the following starting point at Kemet:* Medication Management (Psychiatry)
Main reason(s) for seeking treatment today? *
When did this problem begin? *
Mental health issues experienced recently? *
Currently in treatment for mental health / psychiatry? *
Current psychiatric medications? *
Other past psychiatric medication(not current)? *
Are you on the pill or breatfeeding? * YesNo
Do you have any medication allergies? * YesNo
Are you currently using any Vitamins, supplements or herbal remedies? * YesNo
Are you currently in treatment for substance use? * YesNo
Please describe any mental health or substance abuse treatment you've had,if applicable ? *
Patient first name *
Patient last name *
Date of birth *
Sex Select an optionMaleFemale
Social Security Number *
Phone number *
Address *
Insurance
Insurance ID
Emergency contact name *
Relationship to contact
Emergency phone number *
Preferred pharmacy, pharmacy address + phone number:
NoneLightModerateHeavy
NoneCannabis / Marijuana / EdiblesCocaineBenzodiazepines(Xanax,Klonopin,Valium,etc.)Opioids(Prescriptions pill, heroin,fentanyl,etc.)Designer Drugs(MDMA,spice,K2,Kratom,etc.)
Number of past psychiatric hospitalizations? *
Family history of mental illness? *
Forensic or legal issues related to your treatment?(Criminal offenses,lawsuits) * YesNo
Recent discharge from a psychiartric hospital (last 30 days)? * YesNo
Do you have any compromising or complex health condition significantly impacting your mental health? (Parkinson,gastric bypass needs,etc.)* YesNo
Do you have multiple health condition that require coordination * YesNo
Prior diagonsis of personality disorder,psychotic disorder(schizophrenia,schizoaffective,severe bipolar, or a paronid disorder)? * YesNo
Suicied attempt in the past year? * YesNo
Pcp Name + Phone Number
OBGYN Name + Phone Number (if applicable)
Anything else you'd like for us to know before you start your treatment?
Sleep patterns Select an optionstraightfrontleftright
Eating patterns * Select an optionleftright
Personal hygiene * Select an optiondietyogameditationexcercise
Exercise patterns * Select an optionstraightfrontleftright
Physical functioning * Select an optionupdownleftright
Feeling mood * Select an optionhappysadangercalm
Family relationships * Select an optionfrienddaddaughtermother
Social relationships * Select an optionfriendscollegues
Overall functioning * Select an optionGoodBad Anything else you’d like us to know before the appointment starts? *
Recent work productivity * Select an optionYesNo Who referred you? * Select an optionfriendscollegues
Anything else you’d like us to know before the appointment starts? *
Please sign your name in the area below * Clear
By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Relationship to patient
Date
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