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Date of Evaluation
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Start Time
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Referred By:
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Patient Name :
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D.O.B. :
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Mother's Name :
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Father's Name:
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Primary Guardian :
• • •
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Current School/ Grade Level :
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Chief Complaint:
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Reason for Referral:
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History of Presenting Illness:
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Past Psychiatric History:
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Psychiatric Review of Symptoms:
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Depression
• • •
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Hyperactivity/ Impulsivity
• • •
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Mania
• • •
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Oppositional / Defiant
• • •
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Anxiety
• • •
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Conduct Disorder
• • •
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Psychosis
• • •
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Comments
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Obsessive/ Compulsive :
• • •
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Comments
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Inattention
• • •
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Other :
• • •
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Comments:
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Problems at Home Only:
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Problems at School Only :
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Current Grades:
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Past Grades
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Recent losses :
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Recent Stresses
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Nightmares
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Worries
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Fears
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Phobias
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Recurrent thoughts :
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Compulsive acts :
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Past suicidal plans:
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Suicidal attempts
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Past homicidal plans
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Past Homicidal Attempts
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Guns/ weapons in household
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Legal Problems/ Probation officer name :
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Social History
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Genogram :
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Lives with
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Schooling/ Occupation of Parents
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Relationship with Family members:
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Best Friends
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Extracurricular activities
• • •
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Comments
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Specifics strengths
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Specifics weaknesses
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Parents discipline pattern:
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Rules
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Abuse History
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Abuse:
• • •
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DCFS notified :
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Medical History:
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Primary Care Physician:
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PCP phone # :
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Last Physical Exam :
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Past Hospitalization / Surgeries :
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Medical Problems:
• • •
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Comments :
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Vaccinations :
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Current medications
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Allergies
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Substance abuse
• • •
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Additional Information :
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Describe age, experimental, quantity, maximum, frequency, age of onset, withdrawal symptoms reason for use :
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Female
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Age of Menarche :
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LMP:
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Sexually Active
• • •
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# of Partners
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Contraception use :
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Pregnancies
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Pregnancy Worry:
• • •
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History of STD's
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Worries of HIV
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Developmental History
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Birth:
• • •
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Birth weight
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Exposure during pregnancy:
• • •
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Comments :
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Labor / Delivery
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Hospital
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Problems as Infant
• • •
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Comments:
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School problems:
• • •
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Comments:
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Grades repeated:
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Learning disability
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Milestone/ Skills:
• • •
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Comments:
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Family History
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Family Psychiatric History
• • •
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Comments:
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Family Medication History
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Physical Examination
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Weight:
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Height:
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BP Sitting
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Heart Rate
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Respirations
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AIMS Score
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Biopsychosocial Summary
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Provisional Diagnosis
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AXIS !
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AXIS II
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AXIS III
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AXIS IV
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AXIS V
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Recommendations:
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