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History of Present Illness
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HPI
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Intake info
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Intake Info
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Interim PFSH
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Marital Status
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Lives with
• • •
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Overall progress (FU Pts)
• • •
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Stressors
• • •
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Stressors comment
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Depression
• • •
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Depression comment
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Anxiety
• • •
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Anxiety comment
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ADHD symptoms
• • •
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ADHD comment
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Sleep
• • •
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Sleep comment
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Manic symptoms
• • •
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Mania comment
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Psychotic symptoms
• • •
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Psychosis comment
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Suicidal Ideation
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Suicidal ideation comment
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Substance use
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Substance use comment
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Eating disorder symptoms
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Eating Disorder symptoms (NEW Pts)
• • •
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Eating Disorder comment
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Medical ROS (2-9DET, >10COMP)
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Medical ROS WNL
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Medical ROS Comments
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HEENT: WNL
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HEENT Comment
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Neuro/Endocrine: WNL
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Neuro/Endocrine comment
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CV: WNL
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CV comment
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Resp: WNL
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Resp comment
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GI: WNL
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GI comment
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Hematologic/Lymphatic: WNL
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Hematologic/Lymphatic comment
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Allergic/Immunologic: WNL
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Allergic/Immunologic comment
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Derm: WNL
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Derm comment
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Musculoskeletal: WNL
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Musculoskeletal comment
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Uro/GYN
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Past Medical History
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Medical conditions
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Past surgeries
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Primary care physician
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Additional information
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Past Psychiatric History
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Diagnoses
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Hospitalizations
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Suicide attempts/history of violence
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Current therapist
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Trauma history
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Past medication trials
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Specify past medication trials
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Family History
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Specify family history if any
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Social History (2EST/3NEW PFSH elements for COMP)
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Occupation
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Education
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Relationships
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Children
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Military/Legal
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Upbringing
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Comments
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Substance Use History
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Tobacco
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ETOH
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Recreational drugs
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MSE (COMP if 3 vitals/**)
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MSE WNL
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MSE WNL Comments
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Appearance/Presentation*
• • •
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General appearance comment
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Attitude/Behavior
• • •
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Attitude/Behavior comment
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Motor activity
• • •
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Motor activity comment
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Speech*
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Speech comment
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Language*
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Language comment
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Mood*
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Mood comment
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Affect*
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Affect comment
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Thought process*
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Thought process comment
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Thought content*
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Thought content comment
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Psychosis**
• • •
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Psychosis comment
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Delusions**
• • •
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Delusions comment
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Sensorium*
• • •
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Sensorium comment
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Detail Concentration**
• • •
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Concentration comment
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Detail Memory**
• • •
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Memory comment
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Insight*
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Insight comment
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Judgment*
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Judgment comment
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Impulse control
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Impulse control comment
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Gait* (** if also assess Tone)
• • •
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Gait comment
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