IDENTIFYING INFORMATION
|
|
Patient Sex
|
What brings you here today
|
Patient Age
|
Referral Source
|
Patient Living
|
Relationship Status
|
Patient lives with whom explain
|
Client's Children (names/ages)
|
Patient Other Services
|
Patient Employment Status
|
|
|
CURRENT PROVIDERS
|
|
PCP
|
Other Providers
|
PAST PSYCHIATRIC HISTORY
|
|
Patient Hospitalized
|
Hospitalized
|
When patient hospitalized
|
Psychiatric History Includes
• • •
|
CLIENT'S MEDICAL HISTORY
|
|
Medical/Physical Problems
|
Patient's Surgical Procedures
|
Patient Current Medications
|
Medication Prescriber
|
PATIENT FAMILY MENTAL HISTORY
|
|
Mental illness -Paternal
|
Mental Illness-Maternal
|
explain Mental illness paternal
|
explain mental illness maternal
|
PATIENT'S DEVELOPMENTAL HISTORY
|
|
Patient's Place of Birth
|
|
Patient's # of Siblings
|
Parent's Marital Status
|
Patient Raised by
|
Siblings (Name(s) and Age(s)
|
Pt First Sexual Encounter Age
|
Patient's Family Contact
|
Sexual Orientation(s)
• • •
|
Was This Consentual
|
SPIRITUAL HISTORY
|
|
Practice By Family
|
|
MILITARY SERVICE
|
Spiritual/Cultural Belief System
|
Military Service
|
|
Military - Type of Discharge
|
Military Service Active Duty
|
VOCATIONAL HISTORY
|
|
Vocational History
• • •
|
|
LEGAL HISTORY (Explain if Necess
|
Current Employment
|
Ever Arrested
|
|
Ever Convicted
|
Current Legal Problems
|
TRAUMA & ABUSE HISTORY
|
|
Sexual
• • •
|
|
Describe - Severity of Abuse
|
Describe- Nature of Relationship
|
Physical
• • •
|
|
Describe - Severity of Abuse
|
Describe- Nature of Relationship
|
Emotional
• • •
|
|
Describe - Severity of Abuse
|
Describe- Nature of Relationship
|
Neglect
• • •
|
|
Describe - Severity of Abuse
|
Describe- Nature of Relationship
|
Seen someone injured or die
|
|
PATIENT FAMILY D&A HX
|
|
Paternal - Family Member D&A
|
|
SUBSTANCE USE HISTORY
|
Maternal - Family Member D&A
|
Have you ever used tobacco
|
|
Describe - Duration
|
Nicotine - Age at first use
|
Do you drink alcoholic beverages
|
Tobacco Amount
|
Describe - Duration
|
Alcohol - Age of First Use
|
Do you drink caffeine beverages
|
Alcoholic Beverages Amount
|
Describe - Duration
|
Caffeine - Age at first use
|
Rate you risk for HIV
|
Caffeinated Beverages Amount
|
Experienced Problems With
• • •
|
Risk for STD or Hepatitis
|
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
|
Drug - Age at first use
|
Drug - How often
|
Treatment for Addiction
|
Reactions to Treatment Received
|
Self-help groups - AA
|
Self-help groups - NA
|
self-help groups-Other
|
Self-help groups - Al-non
|
|
Substance Abuse Tx
• • •
|
used substance longer than intended
|
explain
|
unsuccessful efforts trying to stop or cut back
|
explain
|
Spent a lot of time involved in substance use
|
explain
|
Cravings or an intense desire for substance
|
explain, include substances
|
unmet obligations resulting from use
|
|
|
|
Affc'td by alcohol use- Fam Mem
|
|
Affected by drug use- Family mem
|
|
PATIENT’S MENTAL HEALTH STATUS
|
Fam mem alcohol use affc'td most
|
Patient Sleep
• • •
|
Fam mem drug use affected most
|
Hard to fall asleep
|
|
Hard to get back to sleep
|
Sleep - How many hours
|
Appetite/Dietary Habits
• • •
|
|
Appetite/Dietary Habits Duration
|
Sleep - # of wake up
|
Energy level - Usual
|
Appetite/Dietary
• • •
|
Energy Level - Today
|
Appetite/Dietary Comments
|
Practice Safe Sex
|
Energy Level - Past 3 months
|
Suicidal Ideation
|
|
Homicidal ideation
|
|
Reliability-Clinician perception
|
Sexually Active
|
Patient Appearance
|
|
Patient Personal Hygiene
|
Describe Plan/Intent/Means
|
Patient Clothing
|
Describe Plan/Intent/Means
|
Patient Behavior
• • •
|
|
Patient Attitude
• • •
|
Patient Appearance - Other
|
Patient Speech
• • •
|
Patient Personal Hygiene Other
|
Pt Interaction during interview
• • •
|
Clothing (Describe if striking)
|
Patient Mood
• • •
|
Change during interview (describ
|
Pt - Perceptual disturbances
• • •
|
Patient - Eye Contact
|
Patient Orientation to
• • •
|
Patient - Psycho motor Activity
|
Patient Memory
• • •
|
Patient Emotional
• • •
|
Patient Judgment & Insight
• • •
|
Patient - Affect
• • •
|
Patient Temperament
• • •
|
Patient - Thought processes
• • •
|
Support Systems - Family
|
Patient Coordination
• • •
|
Support Systems - Other
|
Able to concentrate
|
CRISIS & RISK ASSESSMENT
|
Emotional Range
|
Crisis Asmt 1 (low) -10 (high)
|
Patient Content of thought
• • •
|
Risk to harm self
|
Support Systems - Friends
|
Given Crisis Number
|
|
Patient's Strengths
• • •
|
|
SUMMARY - Client issues
|
Risk Asmt 1 (low) - 10 (high)
|
|
Risk to harm to others
|
|
Crisis plan necessary
|
|
Patient's Challenges
• • •
|
|
SUMMARY - Recommendations
|