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PAST MEDICAL, FAMILY, SOCIAL HISTORIES
PCP, Referring Provider (as on file)
Therapist
Past Medical History
Past Psychiatric History
Social History: marriages, children, living arrangements
Family Med/Psych history
Occupation/Employment Comments:
Education Level: (highest,difficulties)
Military: (service/discharge/rank/traumas)
Childhood: (ACEs,traumas,life-events)
Legal: (incarceration/charges/felonies)
SUBSTANCE USE DETAILED
Smoking Cessation add-on (3-10 minutes) - add on code: 99406
Nicotine Use: (start/route/duration/intensity/last)
Disorder Criteria (nicotine)
• • •
NICOTINE DEPENDENCE SCALE (FAGERSTROM)
1. How soon after waking do you smoke your 1st cigarette?
2. Do you find it difficult to refrain from smoking in places it is forbidden?
3. Which cigarette would you hate to give up?
4. How many cigarettes a day do you smoke?
5. Do you smoke more frequently in the morning?
6. Do you smoke even if you are sick in bed most of the day?
FAGERSTROM SUM AND INTERPRETATION
Alcohol Use: (start/route/duration/intensity/last)
Disorder Criteria (alcohol)
• • •
ALCOHOL ABUSE SCALE (AUDIT-C)
1. How often do you drink?
2. How many drinks per day when drinking?
3. How often >/=6 drinks on one occasion?
Cannabis Use: (start/route/duration/intensity/last)
Disorder Criteria (cannabis)
• • •
Sedative/Hypnotic/Anxiolytic Use: (start/route/duration/intensity/last)
Disorder Criteria (sed/hyp/anx)
• • •
Opioid Use: (start/route/duration/intensity/last)
Disorder Criteria (opi)
• • •
Stimulant Use: (start/route/duration/intensity/last)
Disorder Criteria (stim)
• • •
Hallucinogen Use: (start/route/duration/intensity/last)
Disorder Criteria (hall)
• • •
Other Substance Use: (start/route/duration/intensity/last)
Disorder Criteria (other substance)
• • •

Baros H&P Med / Fam / Social History Alternate Medical Form

Psychiatrist

There are 2 copies in use.
Published: Nov. 22, 2019, 1:12 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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