Patient Contact Sheet

Patient Name ____________________________________________________________

Patient Home Phone_______________________________________________________

Patient Cell Phone ________________________________________________________

Patient Emergency Contact:

Name ____________________________________________________________

Phone (h) _____________________________(c) _________________________

Psychiatrist:

Name ____________________________________________________________

Phone ____________________________________________________________

Therapist:

Name ____________________________________________________________

Phone ____________________________________________________________
Patient Registration Form
Behavioral Services

Demographics

Today’s Date:___________________________

Patients Last Name:__________________________

Patients First Name:_____________________________ MI _____

Date of Birth:____________________________ Gender: Male Female

Address:_________________________________________
City:____________________________________________

State:___________ Zip:___________ County:__________________________

Home Phone:______________________

Social Security #:_________________________ Is Patient Employed? Yes No

Employer
Name/Address:_________________________________________________________________

Primary Care
Physician:_____________________________________________________________________

Admission Type:

Voluntary Involuntary Inpatient Day Boarder

Emergency Contact Information

Emergency Contact:_____________________________________________
Relationship:________________________

Home Phone Number:____________________________

Alternate Phone Number:______________________________

Insurance Information

Name of Insurance:_______________________________
Policy Holder Name:_________________________________

Social Security Number:___________________________

Contract Number:____________________________________

Policy Holder is: Male Female Date of Birth:_____________________

Policy Holder is: Full Time Part Time Retired Not Employed

Employer Name:_________________________________

Employer Address:__________________________________

PAYMENT OF ACCOUNTS:

The balance of account is payable at the time of admission and patients without insurance are
required to settle their account on admission.

Informed financial consent

I understand and agree to pay all hospital accounts including any denial by - health insurance
funds, work cover, transport accident commission or any other relevant body. I understand that
the hospital will not be liable for any valuables I bring to hospital. Signed person responsible for
account ..............................................................

*Write “as above” if same as Patient

Surname…………..

*Given Names…………….

*Address…………

*Postcode……….

What can I expect from the Spandana Healthcare Centre?

My rights what this means :

Accessibility: I have a right to health care. I can access services to address my healthcare needs.

Safety: I have a right to receive safe and high quality care. I receive safe and high quality health
services, provided with professional care, skill and competence.
Respect: I have a right to be shown respect, dignity and consideration. The care provided shows
respect to me and my culture, beliefs, values and personal characteristics.

Communication: I have a right to be informed about services, treatment, options and costs in a
clear and open way. I receive open, timely and appropriate communication about my health care
in a way I can understand.

Participation: I have a right to be included in decisions and choices about my care. I may join in
making decisions and choices about my care and about health service planning.

Privacy: I have a right to privacy and confidentiality of my personal information. My personal

privacy is maintained and proper handling of my personal health and other information is
assured.

Comment: I have a right to comment on my care and to have my concerns addressed. I can
comment on or complain about my care and have my concerns dealt with properly and promptly.
If you do not understand or require a different language please make the staff aware and they
will assist you. I have read and understand my rights
Behavioral Admission Information Form

Name_____________________________________________________
Date___________________________

Describe the events leading up to your admission in the Spandana

Healthcare.________________________

______________________________________________________________________________

Please describe how you are feeling and the difficulties you are
having.________________________________________________________________________

Are there any specific stressors, life changes, or losses in your life right now? (relationship,
financial, legal, etc)

______________________________________________________________________________

What Symptoms are you experiencing?

□ Depressed Mood □ Anxiety □ Grief □ Hopelessness □ Suicidal thoughts

□ Worthlessness □ Guilt □ Loss of energy □ Difficulty Concentrating

□ Confusion □ Excessive Fear □ Hallucinations

□ Mood Swings □ Manic Symptoms □ Impulsive behavior □ Sensitivity increased

□ Anger □ Agitation □ Unusual thoughts/ideas

□ Sleep Disturbance (decrease) □ Sleep Disturbance (increase)

□ Weight gain □ Weight loss □ Substance withdrawal

□ Symptoms associated with an eating disorder □ Psychological Trauma

Have you ever wished you could go to sleep and

not wake up? □ Yes □ No

Have you had thoughts of killing yourself? □ Yes □ No

Have you been thinking about how you might do

this? □ Yes □ No

Are you intending to act on these thoughts? □ Yes □ No

Have you started working out details on how to kill yourself? □ Yes □ No

Have you ever done anything, started to do anything,or prepared to do anything to end your life?
□ Yes □ No

How long ago did you do any of these?

□ Within the last three months

□ Between three months and a year ago

□ Over one year ago

Do you have access to guns/weapons? □ Yes □ No

Do you currently engage in self-harm behavior?

□ No □ Cutting □ Hair Pulling

□ Burning □ Head banging

□ Other:____________________________

Have you in the past?

□ No □ Yes

Type of self-harm______________________

Have you ever threatened to harm or physically harmed someone? □ Yes □ No

How many times has this occurred? □ N/A □ 1-2 □ 3-4 □ 5 or more

How old were you the first time it occurred? □ 40 or older □ 20-39 □ under 20

Are you having thoughts to harm or kill others now? □ Yes □ No

If yes, please explain

_________________________________________________________________________
Please rate the following mood/thoughts on a 0-10 scale 10 = the highest level

Depression _______ Anxiety _______ Suicide _______ Self-harm ________ Harm to

Others_______

Allergies

Drug Food Environment

____________________ ---------------------- ---------------------------

____________________ --------------------------------- ---------------------------

Medical History

Diabetes:

□ Type I □ Type II □ Hypertension □ High Cholesterol

□ Hyperlipidemia □ Heart Attack

□ Heart Failure □ Atrial Fibrillation □ Stroke/TIA □ Head Injury

□ Seizures □ Hearing Problems □ Vision Problems □ Anemia

□ HIV □ Infection □ COPD/Respiratory □ Asthma

□ Sexually transmitted disease □ Bowel Disease □ Wound/Cut

□ Cancer □ Learning Disability □ Chronic Pain

Other Medical
History________________________________________________________________________

______________________________________________________________________________

Surgical History

_________________________________________________ Date ____________________

_________________________________________________ Date _____________________

_________________________________________________ Date _____________________

Do you have a history of substance abuse? If yes, please describe.

______________________________________________________________________________

Have you sought treatment? If yes, what type/program?

______________________________________________________________________________

How often did you have a drink containing alcohol in the past year?

□ never

□ less than monthly

□ 2 to 4 times per month

□ 2-3 times per week

□ 4 or more times per week

In the past year, how many drinks did you typically have when you drank?

□ 1 or 2

□ 3 or 4

□ 5 or 6

□ 7 or 8

□ 10 or more

How often did you have 6 or more drinks on one occasion in the past year?

□ never

□ less than monthly

□ monthly

□ weekly

□ daily

Have you ever been treated for an alcohol problem or attended AA? □ Yes □ No
Who do you currently reside with?

□ Alone □ Siblings

□ Children □ Significant Other

□ Father □ Spouse

□ Mother □ Other:____________________

What is your employment status?

□ Employed □ Retired □ Unemployed

□ Part-time □ Student □ Other _______________

Highest Education:

□ None □ High School □ Some College

□ University Degree(s)_________________________

□ Post Graduate Degree(s)______________________

How much do you exercise?

□ Not currently exercising

□ ______ minutes per day ______ times per week

□ Type: ____________________________________

Are you sexually active? □ Yes □ No Describe your sexual orientation

______________________________

Do you use contraception? □ No □ Yes,

type____________________________________________________

Pregnancy Status □ Yes, estimated date of delivery_____________ □ No □ Unknown □ Not

Applicable

Date of last menstrual period ________________

What helps you relax or cope?

_____________________________________________________________________________

Is there someone supportive to you other than your emergency contact that you would like to
include in your contact information?

Name_____________________________

Contact information _______________________________________

Mental Health Treatment History

Illness Description Illness Date Hospital or Outpatient Physician/Therapist
Program

Who do you spend time with?

_________________________________________________________________

Has there been a change in your social interaction? □ Yes □ No

Do you have specific ethnic, cultural, spiritual practices that would affect care?

______________________________________________________________________________

Eating Patterns

□ normal eating behaviors □ binge eating □ vomit after eating □ over eating □ under eating

□ irregular meal times □ laxative use □ weight gain □ weight loss

Type of Diet:

□ Regular diet □ Gluten free □ Diabetic □ Lactose Free □ Vegetarian □ Low Cholesterol

□ Low Fat □ Other _____________________

Usual Weight__________ Current weight ___________ Height_____________

Have you lost weight without trying? □ Yes □ No

Have you been eating poorly because of a decreased appetite? □ Yes □ No

Have you recently been on tube feedings? □ Yes □ No

Do you have any large open wounds or wounds that are not healing? □ Yes □ No
Sleeping Patterns

□ normal sleep pattern □ difficulty awakening □ difficulty falling asleep

□ early morning awakening □ frequent urination at night □ oversleeping

□ middle of night awakening □ night terrors □ nightmares

□ restless sleeper □ sleep walking

□ Current hours sleep per night _______________

Abuse History

Have you ever been sexually, emotionally or physically abused by your partner, caregiver, or
someone important to you? □ Yes □ No

Within the past year, have you been hit, kicked or otherwise physically hurt by someone? □ Yes
□ No

Within the last year, has anyone forced you to have sexual activity? □ No □ Yes

Are you afraid of your partner, caregiver, or anyone else? □ No □ Yes

If you answered yes to any of the above questions, please explain further.

______________________________________________________________________________

Tobacco Use

□ never smoker Type of Tobacco Age started to use__________

□ former smoker, quit within the past year □ Cigar

□ former smoker, quit more than a year ago □ Cigarettes _________________________

□ current everyday smoker □ Pipe

□ current some day smoker □ Chewing tobacco

Amount of tobacco per day:

Do you have a history of falling? □ No □ Yes

Do you use a walking aid? □ No □ Yes

Do you have problems with balance? □ No □ Yes

Immunizations

Have you had a Pneumonia Shot in the past 5 years? □ No □ Yes, date_________________

Have you had a Flu Shot this season? □ No □ Yes, date_________________

Please list drug allergies:_____________________________________

Name of Medication Dosage Frequency Length of time

you've taken this

medication

I have reviewed the Current Medications and have considered then when prescribing new
medication

Physician Full Name:……………………………..

Physician Signature :……………………………… Date:…………………..

Activity Therapy Questionnaire

During your admission in the Hospital Program you will be encouraged to participate in a variety
of therapeutic activities called Activity Therapy. The following questions will help to provide
important information in planning activities to best meet your therapeutic needs.

Which of the following group settings do you feel most comfortable in participating in?

__ Adapted Exercise __ Educational Presentations

__ Music Therapy __ Recreational Activities (Games etc.)

__ Spiritual Discussion Group __ Creative Expression

__ Hands-on Artistic Activities __ Off Unit Walks

__ Relaxation Techniques Group __ Treatment Processing Group

Do you have specific physical, emotional or cognitive concerns that may restrict your ability to
participate in an Activity Therapy Group? ___ Yes ___ No

If yes please describe:

___________________________________________________________________

What is the highest level of education you have completed? ___________________

How would you assess your ability to read and write?

___ No Difficulty ___ Some Difficulty ___ Significant Difficulty

Are you experiencing problems in any of the following areas?

__ Depression __ Racing Thoughts

__ Anxiety __ Memory/Concentration

__ Coping with Stress __ Recognizing Harmful Situations

__ Thoughts of Hurting Yourself of Others __ Auditory Hallucinations (Hearing Things)

__ Anger Management __ Visual Hallucinations (Seeing Things)

__ Fatigue/Sleep Difficulties __ Taking Prescribed Medications

__ Appetite __ Alcohol and/or Street Drugs

__ Self-Care/Grooming __ Utilizing Community Support Services

__ Communicating Needs to Others __ Starting and Completing a Task

__ Functioning at Home, Work, or School __ Participating in Leisure Activities

Other:
__________________________________________________________________________

Are you currently employed: __ Yes __ No If unemployed, how long? ______________

On average, how many hours per week do you spend at your job? ____________________

What is your main source of transportation?

__ Driving myself __ Transported by friends/family __Bus __Walking

Other: _________________

The following categories represent different ways in which you might spend your leisure or free
time. What activities do you enjoy that involve:

Being a Spectator _______________________________________________________________

Creativity/Self Expression _______________________________________________________

Family
_________________________________________________________________________

Home Improvement _____________________________________________________________

Intellectual Skills _______________________________________________________________

Physical Activities ______________________________________________________________

Relaxation ____________________________________________________________________

Social Interaction _______________________________________________________________

Spirituality/Support Groups/ Community _________________________________________

______________________________________________________________________________

Travel/Adventure ______________________________________________________________

______________________________________________________________________________
Please list any other activities, which you enjoy that do not fall into these

categories:

______________________________________________________________________________

______________________________________________________________________________

What areas would you like to:

Become more involved in? _______________________________________________________

Find our more information about? ________________________________________________

Increase your skill level in? _____________________________________________________

What specific obstacles are you currently experiencing which limit your ability to participate in a
healthy leisure lifestyle? ________________________________________

______________________________________________________________________________
______________________________________________________________________________