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Reason(s) you are seeking psychiatric evaluation
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Past Psychiatric Hospitalizations (year, reason)
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List all known mental health problems/diagnoses:
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List previous mental health treatment(s):
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Physical health history
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Other medical illness(es)
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Past surgeries
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Height:
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Weight:
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For women, method of contraception
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Number of pregnancies
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Premenstrual/Postpartum depression?
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Last menstrual period
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Family member(s) with mental illness/addiction
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Please describe
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Have you ever attempted suicide?
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Please describe
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Do you have guns in your home?
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Intentionally cut/harmed/burned yourself?
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How do you cope with problems or stress?
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People you can depend on for support?
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List Members of household
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Do you use Caffeine
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How much?
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Do you use Tobacco
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How much?
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Education History
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Describe any problems in school
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Current employment status
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Current Position/Occupation
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Name of Employer
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How long at your current job?
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Military History
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Have you ever been party to a lawsuit?
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Please describe
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Ever been arrested/jailed/imprisoned?
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Please describe
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Restraining order/emergency protective order?
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Please describe
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Charged with spouse abuse/child/elder abuse?
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Please describe
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Ever filed a workers compensation claim?
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Please describe
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List current medications
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List allergies to medications
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