|
What brings you here today
|
|
|
Patient Referred by:
|
|
|
Presenting Problems:
|
|
|
History - By whom
|
|
|
IDENTIFYING INFORMATION
|
|
|
Patient Sex
|
Marital Status
|
|
Patient arrived with
|
Patient Living
|
|
Patient lives with whom explain
|
|
|
Patient Employment Status
|
Patient Assistance
• • •
|
|
Physical Barriers to Treatment
|
Physical Barriers Comments
|
|
Specific Barriers to Treatment
|
Specific Barriers Others
|
|
Patient Current Medications
|
Patient Past Medication
|
|
Patient Other Services
|
|
|
CURRENT PROVIDERS
|
|
|
PCP
|
Specialists
|
|
Therapists (Self)
|
Other
|
|
PAST PSYCHIATRIC HISTORY
|
|
|
Psychiatric History Includes
• • •
|
Describe
|
|
Patient Hospitalized
|
Patient Hospitalised Where
|
|
When patient hospitalised
|
Hospitalised
|
|
Substance Abuse Treatment
|
Substance Abuse Including
• • •
|
|
CLIENT'S MEDICAL HISTORY
|
|
|
Medical/Physical Problems
• • •
|
Any other medical problem
|
|
Patient's Surgical Procedures
|
Tests, Labs
|
|
Patient's Dental Provider
|
Date of Last Dental Service
|
|
Rate you risk for HIV
|
Risk for STD or Hepatitis
|
|
PATIENT FAMILY MEDICAL HISTORY
|
Describe
|
|
Family Medical History
• • •
|
Describe
|
|
FAMILY PSYCHATRIC HISTORY
|
|
|
Paternal - Family Member Diagnos
|
Paternal - Describe Treatment
|
|
Maternal - Family Member Diagnos
|
Maternal - Describe Treatment
|
|
CLIENT'S DEVELOPMENTAL HISTORY
|
|
|
Client's Place of Birth
|
|
|
Development
• • •
|
|
|
Client's Family Biological/Adopt
|
|
|
Development
|
|
|
Client Adopted Age
|
|
|
Client Raised by (Parent)
|
Client's # of Moves in Lifetime
|
|
Parents Currently Married
|
|
|
Client's # of Siblings(Name(s)/A
|
|
|
Siblings (Name(s) and Age(s)
|
|
|
Client's Current Family Contact
|
Describe
|
|
Sexual Orientation(s)
• • •
|
|
|
Client's Sexual Status
|
|
|
CLIENT'S HISTORY
|
|
|
Client Marriage History
|
|
|
Client's Children (names and age)
|
|
|
SPIRITUAL HISTORY
|
|
|
Practice by Family
|
Spiritual/Cultural Belief System
|
|
Spiritual/Cultural Comments
|
|
|
EDUCATIONAL HISTORY
|
|
|
Last School Attended
|
Education History
|
|
Learning Disabilities
|
Learning Disabilities Comments
|
|
Special Education
|
Special Education Comments
|
|
College Training
|
College Training Where
|
|
Vocational Schooling
|
Vocational Schooling Where
|
|
Special Training Where
|
|
|
MILITARY SERVICE
|
|
|
Military Service
|
Military Service Branch
|
|
Military Service Active Duty
|
Military - Type of Discharge
|
|
VOCATIONAL HISTORY
|
|
|
Vocational History
• • •
|
Current Employment
|
|
Current Employment Explain
|
Past Employment
|
|
Past Employment Explain
|
Reason for Leaving
|
|
LEGAL HISTORY (Explain if Necess
|
|
|
Ever Arrested
|
Ever Convicted
|
|
Current Legal Problems
• • •
|
|
|
TRAUMA & ABUSE HISTORY
|
|
|
Sexual
• • •
|
Describe
|
|
Physical
• • •
|
Describe
|
|
Emotional
• • •
|
Describe
|
|
Neglect
• • •
|
Describe
|
|
Ever been in an accident
|
Describe
|
|
Seen someone injured or die
|
Die or Injured Comments
|
|
SUBSTANCE USE HISTORY
|
|
|
Have you ever used tobacco
|
Do you use tobacco now
|
|
Tobacco Amount
|
Tobacco in what form
|
|
Do you drink alcoholic beverages
|
Alcoholic Beverages
• • •
|
|
Alcoholic Beverages Amount
|
|
|
Do you drink caffeine beverages
|
Caffeine Amount Daily
|
|
Treatment for Addiction
|
Describe
|
|
Ever used prescription Med
|
Do you now
|
|
Experienced Problems With
• • •
|
Explaination
|
|
SUBSTANCE USE INFORMATION
|
|
|
Drug - Age at first use
|
Drug - Most recent use
|
|
Drug - How often
|
Drug - How Admin
|
|
Caffeine - Age at first use
|
Caffeine - Most recent use
|
|
Caffeine - How often
|
Caffeine - How Admin
|
|
Marijuana - Age at first use
|
Marijuana - Most recent use
|
|
Marijuana - How often
|
Marijuana - How admin
|
|
Cocaine/Crack - Age at first use
|
Cocaine/Crack - Most recent use
|
|
Cocaine/Crack - How often
|
Cocaine/Crack - How admin
|
|
Hallucinogen - Age at first use
|
Hallucinogen - Most recent use
|
|
Hallucinogen - How often
|
Hallucinogen - How admin
|
|
Heroin - Age at first use
|
Heroin - Most recent use
|
|
Heroin - How often
|
Heroin - How admin
|
|
Opioids - Age at first use
|
Opioids - Most recent use
|
|
Opioids - How often
|
Opioids - How admin
|
|
Meth - Age at first use
|
Meth - Most recent use
|
|
Meth - How often
|
Meth - How admin
|
|
Methamphetamines- Age-first use
|
Methamphetamines-Most recent use
|
|
Methamphetamines- How often
|
Methamphetamines- How admin
|
|
Amphetamines - Age at first use
|
Amphetamines - Most recent use
|
|
Amphetamines - How often
|
Amphetamines - How admin
|
|
Prescription meds- Age-first use
|
Prescription med-Most recent use
|
|
Prescription meds - How often
|
Prescription meds - How admin
|
|
Nicotine - Age at first use
|
Nicotine - Most recent use
|
|
Nicotine - How often
|
Nicotine - How admin
|
|
Other Abuse Comments
|
Substance Abuse Treatment
|
|
Reactions to Treatment Received
|
Experience with self-help groups
|
|
Self-help groups - AA
|
Self-help groups - NA
|
|
Self-help groups - Al-non
|
|
|
CLIENT’S MENTAL HEALTH STATUS
|
|
|
Sleep
|
|
|
Client Sleep
• • •
|
|
|
Sleep - How many hours
|
|
|
Sleep - # of wake up
|
|
|
Hard to fall asleep
|
|
|
Hard to get back to sleep
|
|
|
Appetite/Dietary Habits
|
|
|
Appetite/Dietary Habits
• • •
|
|
|
Appetite/Dietary
• • •
|
Appetite/Dietary Comments
|
|
Energy level
|
|
|
Energy level - Usual
|
|
|
Energy Level - Today
|
|
|
Energy Level - Past 3 months
|
|
|
Libido
|
|
|
Sexual Orientation(s)
• • •
|
|
|
Sexually active
|
Describe
|
|
Libido
• • •
|
Describe
|
|
Client First Sexual Encounter Age
|
Was this consensual
|
|
Practice Safe Sex
|
Describe
|
|
|
|
|
Suicidal/homicidal
|
|
|
Suicidal/homicidal
• • •
|
|
|
Reliability
|
|
|
Reliability-Clinician perception
|
|
|
Appearance
|
Client Appearance
|
|
Client Appearance - Other
|
|
|
Personal Hygiene
|
|
|
Client Personal Hygiene
|
|
|
Client personal hygiene other
|
|
|
Behavior
|
|
|
Client Behaviour
• • •
|
|
|
Clothing
|
|
|
Client Clothing
|
|
|
Clothing (Describe if striking)
|
|
|
Attitude
|
|
|
Client Attitude
• • •
|
|
|
Eye Contact
|
|
|
Client - Eye Contact
|
|
|
Change during interview (describ
|
|
|
Speech
|
|
|
Client Speech
• • •
|
|
|
Psycho motor Activity
|
|
|
Client - Psycho motor Activity
|
|
|
Interaction during interview
|
|
|
Client Interaction during interv
• • •
|
|
|
Mood, Temperament & Emotional
|
|
|
Emotional Range
|
|
|
Client Emotional
• • •
|
|
|
Client Temperament
• • •
|
|
|
Client Mood
• • •
|
|
|
Affect
|
|
|
Client - Affect
• • •
|
|
|
Perceptual disturbances
|
|
|
Client - Perceptual disturbances
• • •
|
|
|
Thought processes
|
|
|
Client - Thought processes
• • •
|
|
|
Content of thought
|
|
|
Client Content of thought
• • •
|
|
|
Information and intelligence
|
|
|
Appropriate to age and education
|
|
|
Orientation to
|
|
|
Client Orientation to
• • •
|
|
|
Able to concentrate
|
|
|
Able to follow instructions
|
|
|
Memory
|
|
|
Client Memory
• • •
|
|
|
Coordination
|
|
|
Client Coordination
• • •
|
|
|
Judgment & Insight
|
|
|
Client Judgment & Insight
• • •
|
|
|
Support Systems
|
|
|
Support Systems - Family
|
|
|
Support Systems - Friends
|
|
|
Support System Community
|
|
|
CRISIS & RISK ASSESSMENT
|
|
|
Crisis plan necessary
|
Describe
|
|
Client's Strengths
• • •
|
|
|
Clinical impression
|
|
|
Client's Challenges
• • •
|
|
|
Prognosis
|
|
|
FIVE AXIS DIAGNOSIS
|
|
|
Five axis diagnosis - #
|
Five axis diagnosis - Description
|
|
Five axis diagnosis by history
|
History - By whom
|
|
AXIS I
|
AXIS II
|
|
AXIS III
|
|
|
AXIS IV
|
|
|
AXIS V
|
|
|
GAF(CURRENT)
|
|
|
Prognosis
|
|
|
SUMMARY - Recommendations
|
|
