|
Patient Age
|
Patient Gender
|
|
Relationship Status
|
Employment Status
|
|
City of Residence
|
|
|
|
|
|
What brings you here today
|
|
|
CURRENT PROVIDERS
|
|
|
PCP
|
Patient Other Services
|
|
Other Providers
|
|
|
PAST PSYCHIATRIC HISTORY
|
|
|
Patient Hospitalized
|
Hospitalized
• • •
|
|
When/Where Patient Hospitalized
|
Psychiatric History Includes
• • •
|
|
Suicide Attempts?
|
If yes, how many times?
|
|
PATIENT'S MEDICAL HISTORY
|
|
|
Medical/Physical Problems
|
Patient's Surgical Procedures
|
|
PATIENT FAMILY MENTAL HISTORY
|
|
|
Paternal - Family Member Dx
|
Maternal - Family Member Dx
|
|
PATIENT'S DEVELOPMENTAL HISTORY
|
|
|
Patient's Place of Birth
|
Parent's Marital Status
|
|
Patient's # of Siblings
|
Siblings: Name(s) and Age(s)
|
|
Patient Raised By
|
Patient's Family Contact
|
|
Pt First Sexual Encounter Age
|
Was This Consensual
|
|
Sexual Orientation(s)
• • •
|
|
|
SPIRITUAL HISTORY
|
|
|
Practice By Family
|
Comment
|
|
Spiritual/Cultural Belief System
|
Comment
|
|
MILITARY SERVICE
|
|
|
Military Service
|
Military Service Active Duty
|
|
Military - Type of Discharge
|
|
|
VOCATIONAL HISTORY
|
|
|
Vocational History
• • •
|
Current Employment
|
|
LEGAL HISTORY (Explain if Necessary)
|
|
|
Ever Arrested
|
Ever Convicted
|
|
Current Legal Problems
|
|
|
TRAUMA & ABUSE HISTORY
|
|
|
Sexual
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
|
|
Physical
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
|
|
Emotional
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
|
|
Neglect
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
|
|
Seen Someone Injured or Die
|
If Yes, Describe
|
|
SUBSTANCE USE HISTORY
|
|
|
Have you ever used tobacco
|
Nicotine - Age at first use
|
|
Describe - Duration
|
Tobacco Amount
|
|
Do you drink alcoholic beverages
|
Alcohol - Age of First Use
|
|
Describe - Duration
|
Alcoholic Beverages Amount
|
|
Do you drink caffeine beverages
|
Caffeine - Age at first use
|
|
Describe - Duration
|
Caffeinated Beverages Amount
|
|
Rate Your Risk for HIV
|
Risk for STD or Hepatitis
|
|
Experienced Problems With
• • •
|
|
|
SUBSTANCE USE INFORMATION
|
|
|
Marijuana - Age at first use
|
Marijuana - How often
|
|
Cocaine/Crack - Age at first use
|
Cocaine/Crack - How often
|
|
Hallucinogen - Age at first use
|
Hallucinogen - How often
|
|
Heroin - Age at first use
|
Heroin - How often
|
|
Opioids - Age at first use
|
Opioids - How often
|
|
Meth - Age at first use
|
Meth - How often
|
|
Methamphetamines- Age-first use
|
Methamphetamines- How often
|
|
Amphetamines - Age at first use
|
Amphetamines - How often
|
|
Prescription meds- Age-first use
|
Prescription meds - How often
|
|
Other Drug - Age at first use
|
Other Drug - How often
|
|
Treatment for Addiction
|
Reactions to Treatment Received
|
|
Self-help groups - AA
|
Self-help groups - Al-non
|
|
Self-help groups - NA
|
Substance Abuse Tx LOC
• • •
|
|
Affc'td by alcohol use- Fam Mem
|
Fam mem alcohol use affc'td most
|
|
Affected by drug use- Family mem
|
Fam mem drug use affected most
|
|
PATIENT’S MENTAL HEALTH STATUS
|
|
|
Patient Sleep
• • •
|
Sleep - How many hours
|
|
Hard to fall asleep
|
Sleep - # of wake up
|
|
Hard to get back to sleep
|
|
|
Appetite/Dietary Habits
• • •
|
Appetite/Dietary
• • •
|
|
Appetite/Dietary Habits Duration
|
Appetite/Dietary Comments
|
|
Energy Level - Usual
|
Energy Level - Today
|
|
Energy Level - Past 3 Months
|
|
|
Libido
• • •
|
Sexually Active
|
|
Practice Safe Sex
|
Safe Sex Method
|
|
Suicidal Ideation
|
Describe Plan/Intent/Means
|
|
Homicidal Ideation
|
Describe Plan/Intent/Means
|
|
Reliability-Clinician Perception
|
|
|
Appearance
• • •
|
Appearance - Other
|
|
Personal Hygiene
• • •
|
Personal Hygiene - Other
|
|
Clothing
|
Clothing (Describe if striking)
|
|
Behavior
• • •
|
Change during interview (describ
|
|
Attentiveness
• • •
|
Eye Contact
|
|
Speech
• • •
|
Psycho Motor
• • •
|
|
Affect
• • •
|
Patient Mood
• • •
|
|
Perceptual Disturbances
• • •
|
Perceptual Disturbances Comment
|
|
Thought Processes
• • •
|
Thought Content
• • •
|
|
Memory
• • •
|
Memory Comment
|
|
Ability to Concentrate
|
Emotional
• • •
|
|
Intellect
|
Patient Orientation to
• • •
|
|
Insight
• • •
|
Judgement
• • •
|
|
Support Systems - Family
|
Support Systems - Friends
|
|
Support Systems - Other
|
|
|
CRISIS & RISK ASSESSMENT
|
|
|
Crisis Asmt 1 (low) - 10 (high)
|
Risk Asmt 1 (low) - 10 (high)
|
|
Risk to Harm Self
|
Risk of Harm to Others
|
|
Given Crisis Number
|
Crisis Plan Necessary
|
|
Patient's Strengths
• • •
|
Patient's Challenges
• • •
|
|
SUMMARY - Patient Issues
|
SUMMARY - Recommendations
|
