Miriam Tetelbom MD   LLC   
Informações   Pessoais: 
Data:__________________________
Nome: _____________________________________________
Data de Nascimento: _____/______/_______  Idade: ________
Endereço Residencial: __________________________________________________
Cidade: _____________________     Estado: ______________ Codigo Postal: ___________
Telefone : casa:___________________ trabalho:____________________________
Celular: _______________________  Email:____________________________
Por favor responda as perguntas seguintes circulando as palavras que melhor  correspondam a sua reposta:
1)Ao circular  essa reposta estou  autorizando a  Dr Tetelbom a me mandar  mensagens por :  
mensagem de texto /mensagem de  voz/email
2)Sexo:  Masculino / Femenino      
 3)Situação  Conjugal: Casado(a)/Solteiro(a)/ Vice com parceiro(a)/Divorciado(a)/Viuvo(a)
Estudo: ____________________________________
Com quem mora:________________________________________________
Ao prover as informaçoes  de uma  pessoa  para contato  em  situações  de emergencia estou  autorizando a Dra  Miriam Tetelbom a  telefonar e/ou escrever para essa pessoa caso  seja necessário e  falando/abrindo  informacoes  para  esta pessoa.que  foram  confidenciadas  durante o tratamento para a Dra Miriam Tetelbom( circule as  informacoes que voce autoriza   serem abertas) diagnostico,tratatmento,riscos    
Nome: _____________________________  
Circule  sua resposta: Esposo(a) Pai  Mãe  Filho(a) Amigo(a)
Endereço_________________________________________________________________________
Telefone Residencial:___________________Celular:___________________________

Presenting Problem(s): 
Please describe your reasons for seeking help at this time (include date/month the problem started)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Was there any event, which made these issues or problems surface?
If so , please describe: _____________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
Are you taking medications? Who prescribed? (Name and dosage and  when       started )___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have  you  ever been in  any other psychiatric medications? What? When? Please  let me know if  they were helpful  or  were  there any side effects?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been diagnosed with a psychiatric condition? What? When? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever had thoughts to hurt yourself or others ? Have you ever  harmed yourself? When was the last time? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever received psychiatric or psychological treatment of any kind before? Yes/No   
 What type of care did you receive?  Single Evaluation /  Outpatient / Psychiatric Admission /Emergency Room  Visit
When? For how long? __________________________________________________________
Who was the therapist or medical doctor? __________________________________________________________________________________________________________________________
What was the treatment focused on?_______________________________________________________________________________________________________________________________________________________________________________________

Substance Abuse History:
Circle the substances you used in a regular basis:
Tobacco____Alcohol_____Marijuana____Cocaine____Opioids____Stimulants
Others: ____________________________________
Have you ever had problematic use? __________________________________________________________
Have you been in any treatment for substance abuse or dependence in the past ? When ? What   type of treatment?  _______________________________________________________________________________________________________________________________________________________________________________________
Nome do  seu medico (medico generalista ,medico de familia)  _______________________  Telefone:_______________    Data de seu ultimo exame anual: _______________________
Problemas de saúde  e medicações     _______________________________________________________________________________________________________________________________________________________________________________________
How  about  over the  counter medications  or natural supplements? _______________________________________________________________________________________________________________________________________________________________________________________
Any Allergies__________________________________________________ 

Family History: Are there any medical or psychiatric conditions in any of your family members? Yes/No Which? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any further information that you consider   important for me to know for this evaluation: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thanks for taking your time to fill out this form
Patient  signature:______________________________________   Date:________________