Psychiatric History
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2Wisconsin Psychiatric
608.263.6100
Institute & Clinics
608.263.0265 Fax
6001 Research Park Boulevard
Madison, WI 53719-1176
Psychiatry
Name______________________________________________________
Appt Date_______________________
Why are you coming to UW Psychiatry and did someone refer you to us?
__________________________________________________________________________________________________
Psychiatric History:
Have you seen a psychiatrist or therapist in the past?
YES NO
Please list below
__________________________________________________________________________________________________
Have you ever been diagnosed with a psychiatric or mental health disorder? YES NO
Depression
Y N
Schizophrenia
Y N
Bipolor Disorder
Y N
Schizoaffective
Y N
Anxiety
Y N
Psychosis
Y N
Panic Attacks
Y N
Attention Deficit/Hyperactivity Disorder
Y N
Social Anxiety
Y N
Learning Disorder
Y N
Post traumatic
Stress Disorder
Y N
Dementia
Y N
Anorexia
Y N
Pathological Gambling
Y N
Bulimia
Y N
Alcohol or drug abuse
Y N
Addictions of any kind
Y N
Have you ever been hospitalized for mental health treatment?
YES
NO
If you indicated yes, please explain:
__________________________________________________________________________________________________
Please circle the psychiatric medication that you have taken in the past:
Buspar – buspirone
Ambien – zolpidem
Depakote – divalproex
Celexa – citalopram
Lunesta – eszopiclone
Lithium – eskalith
Cymbalta – duloxetine
Rozerem – ramelteon
Tegretol – carbamazepine
Effexor – venlafaxine
Desyrel – trazadone
Lamictal – lamotrigine
Lexapro – escitalopram
Luvox – fluvoxamine
Abilify – aripiprazole
Paxil – paroxetine
Valium – diazepam
Clozaril – clozapine
Prozac – fluoxetine
Xanax – alprazolam
Geodon – ziprasidone
Remeron – mirtazapine
Ativan – lorazepam
Risperdal – risperidone
Wellbutrin – buproprion
Klonopin – clonazepam
Seroquel – quetiapine
Zoloft – sertraline
Zyprexa – olanzapine
Elavil – amitriptyline
Haldol – haloporaldol
Pamelor – nortriptyline
Trilafon – perphenazine
Please list any additional psychiatric medication that you have taken in the past:
__________________________________________________________________________________________________
Family Psychiatric History and Medical History
Have any of your family members suffered from any of the above listed psychiatric disorders? Please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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