CURRENT/PAST PSYCHIATRIC HISTORY
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Suicidal Ideation
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Describe Plan/Intent/Means
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Homicidal ideation
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Describe Plan/Intent/Means
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Has the client ever received a mental health diagnosis?
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If yes, Describe:
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Has the client had psychological testing in the past?
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If yes, Describe:
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Has the client ever been prescribed medication(s) for psychological, emotional or behavioral problems?
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If yes, Describe:
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Psychiatric History Includes
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If yes, Describe:
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Patient Hospitalized
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Hospitalised
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When patient hospitalised
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Patient Hospitalised Where
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Hospitalised Medications
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Has any relative had a mental health diagnosis?
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If yes, Describe:
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CLIENT'S MEDICAL CURRENT
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1. How would you characterize clients general medical condition:
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Medical/Physical Problems
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Any other medical problem
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If yes, Describe:
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Does the client see a doctor regularly?
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If yes, Describe:
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When was the client’s last physical examination?
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Has the client ever been hospitalized for a medical condition?
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If yes, Describe:
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Does the client experience any sleeping problems:
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If yes, Describe:
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Appetite/Dietary
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Appetite/Dietary Habits
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Appetite/Dietary Habits Duration
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Appetite/Dietary Comments
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Patient's Disability
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Identify Disability
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Disability Compensation
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Any medical issues regarding the client’s family that should be noted?
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If yes, Describe:
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PATIENT PAST MEDICAL HISTORY
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Patient's Dental Provider
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Date of Last Dental Service
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Patient's Surgical Procedures
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Tests, Labs
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Consultation for substance abuse
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PATIENT FAMILY MEDICAL HISTORY
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Family Medical History
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Paternal family health issue
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Paternal - Describe Medication
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Paternal- Describe Treatment
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Paternal - Treatment Response
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Maternal - Family health issue
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Maternal - Describe Medication
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Maternal - Describe Treatment
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Maternal - Describe Response
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PATIENT FAMILY MENTAL HISTORY
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Paternal Family Mem Health Issue
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Paternal - Describe Medication
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Maternal Family Mem Health Issue
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Maternal - Family Member Diagnos
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