| 1. Reason for visit: |
Tell your doctor exactly why you decided to make an appointment today. Are you interested in discussing particular symptoms? Would you like to talk about ways to better manage relationships with your friends and family? Are you interested in learning more about treatment plans, therapy, or medication? By knowing in advance what your needs are, your doctor will be fully prepared to help you.
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| 2. How you are feeling: |
Rate how you have been feeling on the following scales from 1 to 10 (a rating of "1" signifies the worst your symptoms have ever felt, a rating of "10" is the best you've ever felt). |
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| 3. Symptoms Checklist |
Check the physical and mental symptoms that you have been experiencing. By thoroughly discussing your symptoms with your doctor, he or she will be able to provide the most appropriate treatment plan for you.
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| Lethargy |
| Drowsiness |
| Headache |
| Body Aches |
| Dizziness |
| Chest Pain |
| Sleep Disturbances |
| Change in Appetite |
| Decreased Sexual Drive |
| Muscle Tension |
| Nausea |
| Other |
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| Lack of Concentration |
| Memory Loss |
| Irritability |
| Loss of Pleasure |
| Hopelessness |
| Suicidal Thoughts |
| Nightmares |
| Racing Thoughts |
| Hallucinations |
| Other |
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Other Symptoms |
List any other mental or physical symptoms you may be experiencing. |
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| 4. Prescription Medications |
List all of the prescription medications you are currently taking. |
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| SSRI's (Zoloft, Effexor, Paxil, etc.) |
| MAOI's (Nardil, Parnate, etc.) |
| Benzodiazepines (Klonopin, Atavan, Xanax, etc.) |
| Other |
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| 5. Non-prescription Solutions |
List all non-prescription solutions or medicines you are currently taking including over-the-counter medications, vitamins and herbal supplements. |
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| 6. Current Treatment |
Are you Satisfied with your current treatment? |
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| If NO, Why not? |
| Side Effects |
| Cost |
| Doesn't Work |
| Forget to take It |
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| 7. Alternative Treatment Options |
There are various alternative types of therapy currently available. Check any treatments you may be interested in trying. |
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| Cognitive Behavior Therapy |
| Alternative Medicine (Herbs, vitamins, etc.) |
| Self-Help |
| Family Therapy |
| Talk Therapy |
| Counseling |
| Other |
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