Sunshine Psychiatric Associates, LLC
Richard A. Cottrell, DO
Board Certified Psychiatrist
13787 Belcher Road South Suite 140 Largo, Florida 33771
Office 727-518-7294 Fax 727-584-4937
Patient Information Date: _______ Referred By: ____________ Google, Healthgrades, Zocdoc
Print name:
___________________________ ______ _______________________
(first) (middle initial) (last)
Date of Birth: _________________ Age: ______ Gender (circle): male female other
Primary phone number: _____________________ Alternate phone number: ___________________
Email address: __________________________________________________
Home address:
Education: Grade Completed (circle one): High School, Associate, Bachelors, Masters, Other________
Current occupation: _______________________
Marital Status (circle one): married single divorced partner other
Name of spouse/partner/other: ___________________________________________
Contact: Name _______________________________ Phone: ________________________
Pharmacy phone number: _______________________________________
Pharmacy name and address: ________________________________________
Reason for Appointment (Examples include Depression, Anxiety, Post Traumatic, Attention Deficit, Obsessive Compulsive, Insomnia, Bipolar Affective Disorder, Personality Disorders, Psychosis):
Symptoms onset (age): ________ Current episode onset (date): ___________ Pg. 1
Psychiatric History
Number of Psychiatric Hospitalizations: ______________
Most recent Psychiatric Hospitalization: Date: _____________ Diagnosis: ______________________
Have you attempted suicide? (circle one): Yes No If yes, number of attempts __________
Age of first attempt ______ Age of last attempt _____ How?
Current/Previous Psychiatrists:
Name _______________________________ Dates: ___________
Name _______________________________ Dates: ___________
History of Psychiatric Medications (Put a check next to those that helped): ______________________
___________________________________________________________________________________
Current/Previous Psychologists/Therapists:
Name _____________________________ Duration (approximate month/year): ________________
Name _____________________________ Duration (approximate month/year): ________________
Drug History: Are you currently using any of the following substances?
Drugs (circle if yes)
How often? (at least 1x/day; at least 1x/week, other)
Cigarettes/Vapes
Alcohol/Marijuana
Cocaine/LSD
Heroin/Other
Have you ever misused, abused or sold benzodiazepines (Valium, Klonopin, Ativan, Xanax, etc.) or stimulants (Adderall, Ritalin, Vyvanse, etc.)? (circle if yes)
If yes explain:
Family Doctor Name: __________________________________________________
Phone number: ________________________ Date of most recent physical: _______________ Any Medication Allergies: __________________________________
Identify adverse reactions: ___________________________________________________ Pg. 2
Medical History: Please circle any of the following issues for which you are currently being treated and your current medications:
Medical Issues (circle if yes)
Names of current medications
Depression/Anxiety/ADHD
OCD/Bipolar/etc.
Hypertension/Cardiac Issues
Stroke/Head Trauma/Seizures
Diabetes Type 1/Type 2
Osteoarthritis/Fibromyalgia
Hypothyroidism/GERD
COVID/Pneumonia
Cancer/Other
Your Family’s Psychiatric History Parents/Siblings/Children (only blood relatives)
Diagnosis
List family members (parents, siblings, children)
Depression/Anxiety
Attention Deficit
Obsessive Compulsive
Bipolar Affective
Personality disorders
Psychosis
Drug Abuse
Violence
Is there anything else you would like the Doctor to know?
Signature: ______________________________________ Date: _________________
Thank You! Pg. 3