River Oaks Hospital


Date:		By:

REFERRING THERAPIST:

Name:

Full Address:

City:

State:		Zip:

Phone:		Fax:

PATIENT INFORMATION:

Name:

Age:	Admit Date Requested:

Type of Insurance/Pay arrangements?

Estimated LOS:

PRESENT SYMPTOMS:

depressed mood anxiety panic attacks sleep disturbance appetite disturbance inability to function poor concentration decreased energy hopelessness helplessness anrgy/rageful suicidalidealtion suicide plan(s) past suicide attempt (s) when? how? psychotic other:	flashbacks nightmares isolative behavior dissociative episodes loss of time memory loss self-harming behavior what? eating disorder compulsive overeating restricting binging purging how? laxatives? weight gain weight loss how much?	relationship problems affairs use of prostitutes use of pornography anonymous sex Internet sex voyeurism exhibitionism compulsive masturbation other acting out behavior(s): alcohol/drug abuse sexual identity issues compulsive spending compulsive gambling low self-esteem/worth legal issues what?

TRAUMA HISTORY:

MEDICAL PROBLEMS: (Describe)

MEDICATIONS:

PAST TREATMENT:

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Provider:

City/St:

(From/To:)

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Provider:

City/St:

(From/To:)

InptPhpIOPCpTx:

Provider:

City/St:

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Provider:

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SPECIAL NEEDS (diet, wheelchair, hospital bed, physical/respiratory thrapy, etc.)

ADDITIONAL PERTINENT INFORMATION:

INPATIENT TREATMENT GOALS:

NOTE: Please include or attach laboratory and EKG results on Eating Disorder patients, when necessary.

1525 River Oaks Road West, New Orleans, Louisiana 70123 * 504-734-1740 * 800-366-1740 © 2007 UHS All Rights Reserved | Disclaimer | Notice of Privacy Practices