First visit preparation
What to have ready for your first appointment.
Dr. Patil will cover all of this during your 60-minute evaluation. Having it thought through ahead of time means more of the visit is spent on you - not on paperwork.
Fill it in online and save as PDF
Complete the questionnaire in your browser, then download a filled PDF to bring to your visit.
01
Personal & contact information
- Full legal name
- Date of birth
- Address
- Phone number (best for callbacks)
- Emergency contact name and relationship
- Emergency contact phone number
02
Current concerns
- Main reason for seeking psychiatric care
- When did these concerns begin?
- Have these concerns affected work, school, or relationships? How?
- Any previous psychiatric diagnoses
- Prior hospitalizations for mental health
- Prior psychiatric medications - what helped, what didn't
03
Medical history
- Known medical conditions (thyroid, diabetes, heart disease, etc.)
- Current medications (name, dose, frequency) - include supplements and vitamins
- Drug or food allergies
- Any recent lab work or EKG
- Primary care provider name and contact
04
Family history
- Family history of depression, anxiety, bipolar disorder, or psychosis
- Family history of suicide attempts
- Family members who have taken psychiatric medication - and which ones worked
05
Social history
- Occupation and current work situation
- Living situation (alone, with family, with roommates)
- Current therapist or counselor - if any
- Substance use: alcohol, cannabis, tobacco, other substances
- Sleep patterns - hours per night, difficulty falling or staying asleep
- Exercise habits
06
Safety
- Current or recent thoughts of suicide or self-harm
- Any history of suicide attempts
- Current or past thoughts of harming others
Note on the safety section: Questions about suicide and self-harm are a routine part of every psychiatric evaluation. Answering honestly helps Dr. Patil build the safest and most effective plan for you. Nothing you share will be used against you.