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Accompanied by
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Source Information
• • •
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HISTORY OF PRESENT ILLNESS
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Patient #1
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Symptoms
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Frequency
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Severity
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Exacerbated by
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Improved by
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Previous Treatment
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Response to Treatment
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Patient #2
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Symptoms
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Frequency
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Severity
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Exacerbated by
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Improved by
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Previous Treatment
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Response to Treatment
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Patient #3
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Symptoms
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Frequency
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Severity
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Exacerbated by
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Improved by
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Previous Treatment
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Response to Treatment
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REVIEW OF SYSTEMS
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General: No Change
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If there are changes, please mention
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Integumentary: No Change
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If there are changes, please mention
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HEENT: No Change
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If there are changes, please mention
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Respiratory: No Change
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If there are changes, please mention
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Cardiovascular: No Change
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If there are changes, please mention
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Gastrointestinal: No Change
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If there are changes, please mention
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Genitourinary: No Change
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If there are changes, please mention
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Neurological: No Change
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If there are changes, please mention
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Skeletal: No Change
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If there are changes, please mention
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Endocrine: No Change
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If there are changes, please mention
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Lymphatic: No Change
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If there are changes, please mention
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Other Issues
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PATIENT MEDICAL HISTORY
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PATIENT PSYCHIATRIC HISTORY
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Outpatient Treatment
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Comments
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Inpatient Treatment
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Comments
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Suicide Attempts
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Comments
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Self-Abuse Behaviors
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Comments
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Violence
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Comments
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PATIENT SUBSTANCE ABUSE HISTORY
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Alcohol
• • •
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Details
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Treatment Hx
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Drugs
• • •
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Drugs Used
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Treatment Hx
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Tobacco
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If Former Smoker, Quit Date
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If Active Smoker, PPD
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Caffeine: No hx of use
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Caffeine Comments
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FAMILY MEDICAL HISTORY
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Adopted, no known hx
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Reviewed, unremarkable
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Reviewed, reported family hx is documented below
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Mother
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If other, comments
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Father
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If other, comments
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MGM
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If other, comments
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PGM
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If other, comments
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MGF
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If other, comments
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PGF
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If other, comments
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Sibling 1
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If other, comments
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Sibling 2
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If other, comments
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Sibling 3
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If other, comments
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Sibling 4
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If other, comments
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Other
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FAMILY MENTAL HEALTH HISTORY
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No family medical information known
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All immediate family members alive and well
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Relevant family medical hx documentated below
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Successful Suicide (s)
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If family history, comments
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Suicide Attempt (s)
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If family history, comments
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Violent crime (s)
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If family history, comments
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Alcohol abuse
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If family history, comments
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Drug use / abuse
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If family history, comments
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Diagnosed mental illness
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If Hx, comments
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Any Comments
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PATIENT PSYCHOSOCIAL HISTORY
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Birth Place
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Family of Origin
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Education
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Employment
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Financial Situation
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Marital Status
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Housing
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Living with
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Sexuality
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Hobbies
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Childhood Trauma
• • •
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New Field
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New Field
• • •
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New Field
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New Field
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EXPANDED MENTAL STATUS EXAM
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General
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If other
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Eye Contact
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If other
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Body Type
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If other
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Posture: no abnormality
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Comments
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Gait
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If other
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Coordination
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If other
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Major Activity
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If other
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Reliability
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If other
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Sleep Pattern
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If other
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Delusions
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If other
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Obsessions
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If other
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Compulsions
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If other
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Speech Pattern
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If other
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Fund of Knowledge
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If other
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Abstraction
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If other
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Attention
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If other
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Judgment
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If other
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Memory
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If other
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Mood
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If other
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Affect
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If other
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Thought Processes
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If other
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Hallucinations
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If other
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Dissociative sx's
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If other
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Phobia
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If other
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Suicidal Thoughts
• • •
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Details
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Homicidal Thoughts
• • •
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Details
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Comments
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DIAGNOSIS
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Axis I
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Axis I R/O
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Axis II
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Axis III
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Axis IV
• • •
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If Other
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Axis V
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Comments
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POSSIBLE TREATMENT OPTIONS
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1.)
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2.)
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3.)
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4.)
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5.)
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FORMULATION AND CHOSEN PLAN
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LABS ORDERED
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REFERRALS (IF ANY)
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THERAPY ADD ON
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focused on
• • •
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Additional details r/t therapy if needed
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Reviewed risks / benefits of the treatment plan
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Treatments maybe considered "off label"
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This patient this point in time is
• • •
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FOLLOW UP
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