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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

Psychiatric Evaluation - Initial Medical Form

Psychiatrist

There are 67 copies in use.
Published: Dec. 4, 2018, 12:08 p.m.
Doctor: Dr. History Physical
Rating: +11   /

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