Pennsylvania Mental Health Intake & Evaluation Patient Name: Medical Record #: Date of Birth: Current Age: Date Service Provided: Primary Care Provider: Reason for Referral: Service(s) Provided: Evaluation Procedures: Interview with Review of records Psychological testing: Background Information Medical History: see medical chart for details diabetes per patient history is significant for chronic pain addiction sleep disorder nutrition/obesity/eating disorder cardiac illness fertility issues other hypertension Additional Comments: Current Medications per patient: Current Functioning Orientation: Appearance/Personal Hygiene: Eye Contact: Psychosis: None Auditory visual olfactory gustatory Hallucinations: Delusions: Bizarre Grandiose Jealousy Nihilistic Persecutory Reference Somatic Homicidal Ideation/Intentions: Duty to Protect process completed Insight: Intelligence: Memory/Cognition: Mood/Affect: Angry Expressing Suspicious Anxious Hopeful Tearful
Pennsylvania Mental Health Intake & Evaluation Patient Name: Medical Record #: Date of Birth: Current Age: Date Service Provided: Primary Care Provider: Reason for Referral: Service(s) Provided: Evaluation Procedures: Interview with Review of records Psychological testing: Background Information Medical History: see medical chart for details addiction cardiac illness hypertension diabetes sleep disorder fertility issues per patient history is significant for chronic pain nutrition/obesity/eating disorder other Additional Comments: Current Medications per patient: Current Functioning Orientation: Appearance/Personal Hygiene: Eye Contact: Psychosis: Hallucinations: None Auditory visual olfactory gustatory Delusions: Bizarre Grandiose Jealousy Nihilistic Persecutory Reference Somatic Homicidal Ideation/Intentions: Duty to Protect process completed Insight: Intelligence: Memory/Cognition: Mood/Affect: Angry Anxious Expressing Hopeful Suspicious Tearful
pennsylvania-intake-form.docx