Amy E. Kerr, PhD, LLC
7807 E Funston St
Wichita, Ks 67207
316-636-1188 Fax: 316-636-1190
WELCOME, PLEASE COMPLETE THIS INITIAL INTAKE FORM
Name:
Today’s Date:
Date of birth:
Do you come by referral?
What brings you to this appointment?
Family Physician:
or on your own?
When did this start?
Have there been periods when it has been worse?
Have there been periods where it has been better?
What are the primary symptoms that you experience?
What symptoms worry or bother you the most?
Has there been any change in frequency of symptoms?
Has there been any change in symptom intensity?
Has there been any change in symptom duration?
What tends to make the problem better?
What tends to make the problem worse?
What might be the causing problems?
Have you ever sought out treatment before?
With whom?
How was it helpful?
Any previous Psychological Testing?
When?
What were the results?
How would you like things to be different in 6 months?
MEDICAL HISTORY AND INFORMATION
Please list any surgeries, hospitalizations, illness, or medical problems:
Which specialists do you see currently?
Are you allergic to any medicines?
Please list any allergies to substances or foods
Please list any/all medicines you are taking currently:
Medicine
Dosage
Purpose
Start Date
Please list here any medicines you have taken in the past:
Medicine
Dosage
Purpose
Start Date
Any job-related injuries?
Any History of serious falls?
N Y
Physician
Physician
When?
Any seizure activities?
N Y First onset?
How treated?
Losses of consciousness?
NY
If more than one incident, please indicate the following for each incident:
At What ages?
What happened?
Were you seen by a physician?
Evaluated in the ER?
What changes (in personality or behavior) did you note after any of those incidents?
Any auto accidents?
Was Alcohol involved?
Any history of electrical shocks?
Any exposure to toxic chemicals/solvents/work-place hazards?
You or anyone in the family had/have:
Cancer
Diabetes
Hypertension
Lung/breathing problems
Stroke Dementia
Heart disease
Kidney Problems
Heart Surgery
Hepatitis
Hearing Impairment
RELATIONSHIP STATUS
Marital Status (circle one): Single
Committed Relationship
Married
Divorced
Partner name and age:
Children’s name and ages:
Marital/Relationship satisfaction?
Specific Concerns?
FAMILY MEDICAL HISTORY
Any family history of the following being present on either your mother’s (put “M”) or father’s
(put “F”) side of the family: Please include siblings, grandparents, aunts, uncles, cousins,
nephews, nieces, offspring, etc. If any apply to you, now, or in the past, put an “S” for self.
Anxiety
Panic Attacks
Perfectionism
Obsessive Compulsive Disorder
Depression
Manic Depression/Bipolar
Suicide attempts
Psychiatric Hospitalizations
Alcohol problems
Post Traumatic Stress
Hyperactivity
Learning difficulties
Driving under the influence
Problems completing school
Drug Use
Attention Deficits
Contact with the law
On disability
Eating Disorders
Personality Problems
Seizures
Anger problems
Epilepsy
Traumatic Events
Divorce
Sexual Problems
Significant Losses
Breaks with reality
Prison
Sleep Problems
Extra-marital affairs
History of: abuse, neglect, and/or molestation?
History of: rape and/or date rape?
Any other concerns on either side of the family?
Anything you wish to add?
BACKGROUND DATA
Where did you grow up?
What did your mother do?
What did your father do?
With whom did you live with growing up? List all members and when you lived with them.
Any serious health issues amongst your family members?
Did your parents stay together?
Or divorce?
If divorced, how old were you when they divorced?
How would you describe the post-divorce time for you?
For other family members?
Do you have siblings? Ages, and whereabouts now?
With whom were you closest in the family with growing up?
And now?
How is your father’s health?
How is your mother’s health?
Did you grow up in a blended family?
Do you use tobacco?
When did that occur?
Form and Amount?
Do you use marijuana?
Did you use as a teenager?
How often?
When did you first start?
How often do you drink alcohol?
When did you first start?
How often do you drink to excess?
Any current drug use?
Circle any of the following you have tried in the past:
Amphetamines
Cocaine
Crack
Ecstasy
Heroin
Uppers
Sedatives
Marijuana
Mescaline
Mushrooms
Opium
Hashish Designer drugs
Cold
remedies
LSD
over-the-counter medicines Glues/paint/fumes/ gasoline huffing
Ephedrine
Muscle relaxants
Anabolic Steroids
Are you sexually active?
Are you active spiritually?
Are you content in this area?
any formal affiliation with a religious group?
Is that a source of strength/ support for you?
On a 1-10 scale, how important is your faith to you now?
Growing up?
To your family now?
To your family when you were growing up?
If there are questions not asked that you deem important about yourself, please give that
information here. Also, please write on the back any particular questions you would like to be
asked during the interview. I look forward to meeting with you.
-Amy Kerr, PhD