MAHESH R. DAVE, M.D.P.A
1201 D Briarcrest Drive Bryan, TX 77802
979-776-5600
PATIENT’S NAME:
YOUR MAIN COMPLAINT: (Please circle all that applies)
Anxiety/Panic Depression Mood swings Attention Problems Addiction
MEDICAL HISTORY: (Please be truthful 100% - Put checkmarks in the table):
Condition
Yes
Check
No
Check
Comments –treated in hospital,
which drug/meds used etc
Diabetes
High Blood Pressure
Thyroid Problems
Weight Loss (Anorexia)
Weight Gain (Obesity)
Cancer
Asthma
Seizures
Head Injury
Pain
Sex Problems
Bladder Problems
Surgeries
Are you pregnant now?
PSYCHIATRIC HISTORY: (Please be truthful 100% - Put checkmarks in the
table):
Condition
Yes
No
Comments –treated in hospital,
Check
Check
which drug/meds used etc
DEPRESSION
BIPOLAR-MANIA
SCHIZOPHRENIA
PSYCHOSIS
ANXIETY PANIC
ADHD
DWI?
DUI?
ALCOHOL PROBLEMS
DRUG PROBLEMS
EATING DISORDERS
How many attempts:
SUICIDE ATTEMPTS
Once you complete these forms, please fax to 979-776-6280 or bring them with you
MAHESH R. DAVE, M.D.P.A
1201 D Briarcrest Drive Bryan, TX 77802
979-776-5600
Who is prescribing Psychiatric Medications to you at this time? _________________
Has your personal doctor (PCP) ever referred you to a Psychiatrist? Yes
No
If you attempted suicide, how many times? ____________
How did you attempt suicide: Overdose – Cutting on me – Attempted to use gun
Used drugs or alcohol – Other method ________________________
Who saved you from above attempt? I quit the attempt – I called someone
Someone found me – Something else happened.
Were you using drugs or alcohol during the suicide attempt?
Yes. No.
Were you treated after attempt? Yes. No. If yes, who treated you?
Where were you treated?
Have you ever attempted to harm any one else in past?
Have you been abused in the past? If yes, tell us how you were abused and by
whom?
OTHER PSYCHIATRIC HISTORY (Please describe):
LIST YOUR ALLERGIES BELOW:
MEDICINE ALLERGIC Circle Names of All Psychiatric meds you are allergic
YES OR
to:
NO
Penicillin
Sulfa
Antibiotics
Aspirin
Other
Allergies
Tylenol
Once you complete these forms, please fax to 979-776-6280 or bring them with you
MAHESH R. DAVE, M.D.P.A
1201 D Briarcrest Drive Bryan, TX 77802
979-776-5600
CIRCLE ALL PSYCHIATRIC MEDICINES THAT DID NOT WORK FOR YOU:
Prozac, Zoloft, Celexa, Lexapro, Luvox, Cymbalta, Effexor, Pristiq, Seroquel,
Zyprexa, Geodone, Depakote, Tegretol, Lamictal, Trileptal, Lyrica, Gabapentin
LIST YOUR CURRENT MEDICATIONS:
NAME OF
DOSE
MEDICATION
HOW
FREQUENT
SIDE
EFFECTS?
COMMENTS
FAMILY PSYCHIATRIC HISTORY: Please put check marks in the table)
Depression Bipolar Anxiety Alcohol Drug
Abuse
Abuse
ADHD
Suicide
Dad
Mom
Siblings
Grandfather
Grandmother
Children
Have you or any one in the family got a bad temper?
Has any one in your family been accused by the law of DWI or DUI, or temper
problems? (please describe):
Once you complete these forms, please fax to 979-776-6280 or bring them with you
MAHESH R. DAVE, M.D.P.A
1201 D Briarcrest Drive Bryan, TX 77802
979-776-5600
SOCIAL HISTORY:
Which town you were born in? __________________
Where did you grow up? _______________________
Circle the following as it pertains to you:
Marital Status:
Single, Married, Separated, Divorced, Widowed, Significant Other
How many times you have been married? ______
With whom do you live? _____________________________
Habits (cups or cans in a day):
Coffee _____ Tea _____ Colas ___ per day. I mostly/only drink water.
Alcohol (Circle) : Never. Less than 1 drink/beer per week. 1-5 per week. More than 5
per week. Please describe your CURRENT alcohol use:
Drugs Used in Past: Never used.
Marijuana
Cocaine Methamphetamines LSD Ecstasy
Inhalants-gas/spray Please describe your PAST drug use:
Mushrooms
Drugs Used Now: None.
Marijuana
Cocaine Methamphetamines LSD Ecstacy Mushrooms
Inhalants-gas/spray Please describe your CURRENT drug use:
Tobacco:
Cigarettes: Never. Quit __ years ago. Still smoke___ per day for __Years.
Employed? Full Time Part Time I am at home. I am a student.
Please describe your job: ___________________________________
________________________________________________________
Education:
Are you a student? ____ where________________
Finished Grade School _____ College _____ Postgraduate _________
Safety: Do you wear seatbelts? All the time. Sometimes. Never.
Do you use cane/walker? All the time. Sometimes. Never.
Do you wear “Emergency Call Device?” Yes. No.
Do you know how to use “911” service?
Yes. No.
Do you have a living will? Yes. No.
Once you complete these forms, please fax to 979-776-6280 or bring them with you
MAHESH R. DAVE, M.D.P.A
1201 D Briarcrest Drive Bryan, TX 77802
979-776-5600
Once you complete these forms, please fax to 979-776-6280 or bring them with you