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PRESENTING PROBLEM:
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SYMPTOM DESCRIPTION AND SUBJECTIVE REPORT:
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Current Psychotropic Medications:
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Physical System Review
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History of Present Problem:
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Onset / Timing
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Severity
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Duration
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Modifying Factors
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Information / Identification of presenting problem
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Additional Information:
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CURRENT MENTAL STATUS:
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GENERAL APPEARANCE:
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Motor Activity:
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DRESS:
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Judgment:
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Insight:
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Affect:
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Mood:
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Orientation:
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Memory:
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Attention/Concentration:
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Thought Content:
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Perception:
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Flow of Thought:
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Interview Behavior:
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Speech:
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SAFETY ISSUES ***REQUIRED***
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Safety Issues: DO YOU HAVE ANY CURRENT THOUGHTS OF HARMING YOURSELF OR OTHERS?
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If yes, please complete the following below:
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History of Safety Issues / Suicide attempts:
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Self-Injuring Behavior:
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Suicidal Ideation:
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Homicidal Ideation:
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Other:
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NEW PATIENT INFORMATION:
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Past Psychiatric History:
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Past Psychological Testing in previous 3 years?
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History of Therapy -
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History of Psychiatric Medications
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Previous Psychiatric Hospitalizations
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Outcome of Treatment
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Major Depressive Disorder Symptoms
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MDD comments:
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GAD physical symptoms
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Anxiety/Panic comments
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Hx of mania symptoms such as
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Bipolar/manic symptom comments
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Obsessive Compulsive Disorder
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OCD comments:
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PTSD
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PTSD comments:
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History or current eating disorder?
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Eating disorder comments:
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Hyperactivity type symptoms
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Inattentive Criteria Symptoms
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Symptoms clearly reduce quality of functioning
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ADHD Assessment comments
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Symptoms present before age 12
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Associated MH signs and symptoms
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Background Information:
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Medical History:
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Medical Allergy:
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Current Medical Conditions:
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Expanded Information:
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Past Medical Issues (Resolved)
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Surgical History
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Do you have a history of ever having a seizure?
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If yes, add details here
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Are you Sexually Active? PLEASE OPEN THE SWITCH TO VIEW QUESTIONS
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Do you use a form of contraception?
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Contraception type and STI precautions
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How many and what relationship of current sexual partners do you have?
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Do you actively use STD precautions?
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FOR WOMEN ONLY. PLEASE OPEN THE SWITCH TO VIEW QUESTIONS
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Last menstrual period:
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Are you currently trying to become pregnant?
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Spontaneous Termination (Miscarriage) or Elected Termination
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Gravida (# of confirmed pregnancies) & Para (# of births>20 weeks:)
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Are symptoms worse around menstrual period?
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Details
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ALCOHOL USE
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Use Start Date
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Date of last use + Hx of Treatment or Self-Help Group
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Amount
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Frequency
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Substance Use
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Type of Substance:
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Use Start Date
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Date of last use + any Hx of Treatment or Self-Help Group
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Amount
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Frequency
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Caffeine Use:
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Amount & Type:
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Nicotine Use:
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Amount & Type:
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Developmental History:
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Turn switch if Within Normal Limits
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Delays:
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Adverse illnesses / injuries:
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General Health as a Child:
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Educational / Occupational History:
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Educational History:
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Occupational History:
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Family History:
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Family of origin
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Where were you born?:
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Relationship with: parents, siblings, significant others growing up & Current:
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Family Medical History: Include Biological Parents, Brothers, Sisters, and Grandparents, and current children:
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Medical Allergy:
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Current Medical Issues:
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Social History:
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Current Relationship status:
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Significant relationship History:
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Social support:
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Nature & quality of relationships:
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Religious Preference:
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Legal History:
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Arrest history:
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Incarceration: Date, duration, location
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Current litigation or legal involvement:
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Self-Identified Strengths / Limitations
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Strengths / Limitations:
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Other information you want to share:
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Current Relevant Content:
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Sleeping:
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Sleep Disruption:
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Details:
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Eating:
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Appetite/weight changes within last month
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Disrupted Eating Patterns:
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Details:
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Sexuality:
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Sexuality:
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Details:
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Family Psychiatric History:
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Family Psychiatric History
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Trauma History:
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Sexual:
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When did it occur:
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Persons involved / Continued Exposure?
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Physical:
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When did it occur:
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Persons involved / Continued Exposure?
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Emotional:
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When did it occur:
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Persons involved / Continued Exposure?:
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Verbal:
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When did it occur:
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Persons involved? / Continued Exposure?:
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Neglect:
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When did it occur:
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Persons involved? / Continued Exposure?
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Phobia attached to any form of trauma?
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OBJECTIVE
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OBJECTIVE NOTES:
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DIAGNOSTIC
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DIAGNOSTIC IMPRESSIONS:
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Depression Rating
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Anxiety rating scale
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Assessments used:
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Additional Information:
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Diagnosis ICD-10:
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CPT:
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TREATMENT PLAN
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Additional Diagnostics:
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PLAN:
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Laboratory Testing:
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Imaging/ Diagnostic Testing:
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INTERVENTIONS USED TODAY OR RECOMMENDED FOR FUTURE:
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Select all that apply:
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Comments:
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AGREEMENTS:
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Patient:
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Free text box
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MEDICATION:
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SSRI:
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SNRI:
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Serotonin Modulators:
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Tricyclic:
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H-Anxiolytic:
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Anxiolytic (Non-benzo):
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NRI & Alpha Agonist:
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Antipsychotic:
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Beta Adrenergic (BB):
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Anti-Convulsant:
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BPDO
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Stimulants:
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Supplements:
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Prescribed / Recommended Medication / Discussion
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RECOMMENDATION:
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Continue Current Treatment Plan
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Comment:
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Change Medication
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Comment:
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Change Therapy Treatment
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Comment:
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Terminate Treatment
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Comment:
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Goals:
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Discharge Plan:
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** FOLLOW UP VISIT:
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return in
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Do you give permission for ongoing regular updates to be provides to your therapist if indicated?
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