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IDENTIFYING INFORMATION
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Patient Sex
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Patient Age
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Relationship Status
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Referral Source
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Term
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College/Major/GPA
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Patient Living
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Patient lives with whom explain
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Patient Employment Status
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Client's Children (names/ages)
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Patient Other Services
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What brings you here today
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CURRENT PROVIDERS
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PCP
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Other Providers
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PAST PSYCHIATRIC HISTORY
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Patient Hospitalized
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Hospitalized
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When patient hospitalized
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Psychiatric History Includes
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CLIENT'S MEDICAL HISTORY
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Medical/Physical Problems
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Patient's Surgical Procedures
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Patient Current Medications
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Medication Prescriber
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PATIENT FAMILY MENTAL HISTORY
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Paternal - Family Member Dx
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Maternal - Family Member Dx
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PATIENT'S DEVELOPMENTAL HISTORY
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Patient's Place of Birth
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Parent's Marital Status
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Patient's # of Siblings
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Siblings (Name(s) and Age(s)
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Patient Raised by
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Patient's Family Contact
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Pt First Sexual Encounter Age
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Was This Consentual
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Sexual Orientation(s)
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SPIRITUAL HISTORY
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Practice By Family
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Spiritual/Cultural Belief System
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MILITARY SERVICE
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Military Service
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Military Service Active Duty
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Military - Type of Discharge
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VOCATIONAL HISTORY
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Vocational History
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Current Employment
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LEGAL HISTORY (Explain if Necess
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Ever Arrested
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Current Legal Problems
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Ever Convicted
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TRAUMA & ABUSE HISTORY
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Sexual
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Physical
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Emotional
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Neglect
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Seen someone injured or die
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PATIENT FAMILY D&A HX
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Paternal - Family Member D&A
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Maternal - Family Member D&A
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SUBSTANCE USE HISTORY
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Have you ever used tobacco
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Nicotine - Age at first use
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Describe - Duration
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Tobacco Amount
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Do you drink alcoholic beverages
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Alcohol - Age of First Use
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Describe - Duration
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Alcoholic Beverages Amount
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Do you drink caffeine beverages
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Caffeine - Age at first use
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Describe - Duration
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Caffeinated Beverages Amount
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Rate you risk for HIV
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Risk for STD or Hepatitis
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Experienced Problems With
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SUBSTANCE USE INFORMATION
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Marijuana - Age at first use
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Marijuana - How often
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Cocaine/Crack - Age at first use
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Cocaine/Crack - How often
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Hallucinogen - Age at first use
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Hallucinogen - How often
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Heroin - Age at first use
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Heroin - How often
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Opioids - Age at first use
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Opioids - How often
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Meth - Age at first use
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Meth - How often
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Methamphetamines- Age-first use
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Methamphetamines- How often
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Amphetamines - Age at first use
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Amphetamines - How often
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Prescription meds- Age-first use
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Prescription meds - How often
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Drug - Age at first use
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Drug - How often
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Treatment for Addiction
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Reactions to Treatment Received
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Self-help groups - AA
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Self-help groups - Al-non
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Self-help groups - NA
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Substance Abuse Tx LOC
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Affc'td by alcohol use- Fam Mem
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Fam mem alcohol use affc'td most
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Affected by drug use- Family mem
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Fam mem drug use affected most
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PATIENT’S MENTAL HEALTH STATUS
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Patient Sleep
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Sleep - How many hours
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Hard to fall asleep
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Sleep - # of wake up
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Hard to get back to sleep
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Appetite/Dietary Habits
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Appetite/Dietary
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Appetite/Dietary Habits Duration
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Appetite/Dietary Comments
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Energy level - Usual
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Energy Level - Today
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Energy Level - Past 3 months
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Libido
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Sexually Active
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Practice Safe Sex
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Suicidal Ideation
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Describe Plan/Intent/Means
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Homicidal ideation
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Describe Plan/Intent/Means
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Reliability-Clinician perception
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Patient Appearance
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Patient Appearance - Other
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Patient Personal Hygiene
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Patient Personal Hygiene Other
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Patient Clothing
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Clothing (Describe if striking)
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Patient Behavior
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Change during interview (describ
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Patient Attitude
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Patient - Eye Contact
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Patient Speech
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Patient - Psycho motor Activity
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Pt Interaction during interview
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Patient Emotional
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Patient Mood
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Patient - Affect
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Pt - Perceptual disturbances
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Patient - Thought processes
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Patient Orientation to
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Patient Coordination
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Patient Memory
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Able to concentrate
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Patient Judgment & Insight
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Emotional Range
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Patient Temperament
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Patient Content of thought
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Support Systems - Family
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Support Systems - Friends
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Support Systems - Other
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CRISIS & RISK ASSESSMENT
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Crisis Asmt 1 (low) -10 (high)
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Risk Asmt 1 (low) - 10 (high)
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Risk to harm self
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Risk to harm to others
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Given Crisis Number
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Crisis plan necessary
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Patient's Strengths
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Patient's Challenges
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SUMMARY - Client issues
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SUMMARY - Recommendations
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FIVE AXIS DIAGNOSIS
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AXIS I
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Comment
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AXIS II
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Comment
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AXIS III
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Comment
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AXIS IV
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Comment
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AXIS V (Current)
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GAF (Long Term)
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