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New patient information 9 pp rx

Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 PERSONAL INFORMATION - Please fill out this form as completely as you can. Please print your answers.
Contact Information - Please give your home address. Please circle the appropriate letter letting me know if I can leave a full message (M), call-back number only (C), or no message (N).
Emergency Contact - Please tell me the name of someone to contact in an emergency.
Insurance Information - Although I do not participate with any insurance plans, it is sometimes helpful for me to have your insurance information in case you need hospitalization.
Referral Source - Please tell me who suggested that you see me.
Pharmacy - Please provide contact information for the primary pharmacy you use for your prescriptions.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 DOCTORS AND THERAPISTS - Please list all doctors and therapists you see regularly. Please also list any past psychiatrists and therapists. Continue on back if needed.
Medical Problems - Please list all major medical problems/injuries and treatments. Continues on next page. Continue on back if needed.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 Surgeries - Please list all surgeries you have had, when and for what conditions. Continue on back if needed.
Current Medications and Supplements - Please list all medications and supplements (prescribed and over-the-counter) you take regularly. Continue on back if needed.
Allergies and Adverse Reactions - Please list any medications or foods to which you have had a bad reaction, including problems with anesthesia. Continue on back if needed.
Recent Symptoms and Tests - Please check any symptoms or tests you have had in the past year. Please indicate which body part was tested where applicable (Xray of: chest, e.g.). Continues on next page. Continue on back if needed.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 ☐ Breast lump/new discharge/skin change Substance Use History- For any substances you have ever used, please indicate date of last use, the maximum amount and frequency used, and whether ever used intravenously if applicable. Continues on next page. Continue on back if needed.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 Past Psychiatric Hospitalizations - Please list any psychiatric hospitalizations you have had. Continue on back if needed.
Psychiatric Medications - Please check any medications you have taken and list any psychiatric medications you have taken that are not listed. Continues on next page. Continue on back if needed.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 Family Psychiatric History - Please list any blood relatives diagnosed with a mental illness. (One relative per row please.) Continue on back if needed.
Family Suicide History - Please list any blood relatives who have committed suicide. Continue on back if needed.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 Recent Psychiatric Symptoms - Please check any symptoms you have had during the past two weeks (or longer).
☐ Thoughts being inserted ☐ Afraid to get fatinto your head WOMEN’S HISTORY QUESTIONS (for female patients only) Family History - Please list any female blood relatives who suffered from an episode of mental illness within one year after giving birth. (One relative per row, please.) Continue on back if needed.
Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 Reproductive Events - Please indicate the number of events and when they occurred. Continue on back if needed.
Stillbirths or loss after 20 weeks gestation How old were you when you got your first menstrual period? Premenstrual Symptoms - Have you experienced symptoms that start before your period and stop with bleeding onset? Please check severity level of each.
Depressed mood/hopelessness/self-deprecating thoughts Anxiety/tension/feelings of being “keyed up” or “on edge” Easily sad/tearful/increased sensitivity to rejection Breast tenderness, headache, joint/muscle pain, bloating, weight gain How badly have these symptoms interfered with your: Relationships with family, friends and coworkers? If yes to any of the above symptoms, do they occur with every or most cycle(s)? Y N Jennifer Teitelbaum Palmer M.D.
3355 Keswick Road ✦ Suite 100 Baltimore MD 21211 Reproductive Treatments and Mood Effects - Please indicate whether hormone treatments have affected your mood in any way. Continue on back if needed.
Have you ever used a hormone birth control method (pills, Nuva Ring, Patch, IUD) or other hormone treatment (such as for polycystic ovarian syndrome or missed menses) or hormone replacement therapy? If yes, which treatments? If yes, did you experience any mood changes (better or worse) with these treatments? If yes, please Have you experienced any mood symptoms that started within 4 weeks of delivery or pregnancy termination? If yes, please describe:

Source: http://www.jenniferteitelbaumpalmer.com/docs/jstp_initial_patient_info.pdf

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