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Patient Age
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Patient Gender
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Relationship Status
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Employment Status
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City of Residence
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Presenting problem
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What brings you here today
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What do you hope to get out of treatment ?
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How severe is your problem? ( Scale 1-10)
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Additional Comments
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Housing/ Family Composition
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Current living arrangement :
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How many times have you moved in the past two years ? Why ?
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What else do you think is important for us to understand about your housing/ living situation ?
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Who lives in your Home ?
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Additional comments
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Do you have children ?
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Children/Name/Age/ Living in the Home?
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Who has physical custody ??
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Who has legal custody ?
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Do you have contact ?
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Comment
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Special circumstances (DCFS/ grandparents, etc):
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If adult children, were they always in your care ? Yes-No why ?
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Educational/ Military History/ Employment History
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Education
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Why didn't you finish ?
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Highest grade completed
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Additional Information:
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Education Assistant :
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Additional Information
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VOCATIONAL HISTORY
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Specialty training or Vocational training (ie. Auto mechanics, beauty, etc.). What? y
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How many year? Major? Where? Reason not completed
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Employment History
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Current Employment
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CURRENT PROVIDERS
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Additional Information
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PCP
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Patient Other Services
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Other Providers
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PAST PSYCHIATRIC HISTORY
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Patient Hospitalized
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Hospitalized
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When/Where Patient Hospitalized
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Psychiatric History Includes
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Suicide Attempts?
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If yes, how many times?
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PATIENT'S MEDICAL HISTORY
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How would you describe your overall health ?
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Primary Physician ?
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Date of last medical appointment ?
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Medical/Physical Problems
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Patient's Surgical Procedures
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Dental Problems
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Vision Problems
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Do you need to see doctor now ?
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Advanced Directives
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Female:
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Pregnancy/Abortion/Miscarriages
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Currently Pregnant
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Receiving prenatal care ?
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PATIENT FAMILY MENTAL & HEALTH HISTORY
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Paternal - Family Member Dx
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Maternal - Family Member Dx
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Family health history
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Current Mediations Purpose
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Effectiveness/ Side Effects:
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Previous medications?
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Medication allergies/ Reaction
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Other medication:
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Interest/ Hobbies
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Current or Recent Stressors
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PATIENT'S DEVELOPMENTAL HISTORY
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Patient's Place of Birth
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Parent's Marital Status
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Patient's # of Siblings
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Siblings: Name(s) and Age(s)
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Patient Raised By
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Patient's Family Contact
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Pt First Sexual Encounter Age
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Was This Consensual
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Sexual Orientation(s)
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Military History
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MILITARY SERVICE
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Military Service
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Military Service Active Duty
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Military - Type of Discharge
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Spiritual History
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SPIRITUAL HISTORY
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Practice By Family
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Spiritual/Cultural Belief System
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Ethnicity/Cultural Background/Religion/Spiritually significant
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Legal HIstory
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LEGAL HISTORY (Explain if Necessary)
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Ever Arrested
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Ever Convicted
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Current Legal Problems
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TRAUMA & ABUSE HISTORY
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Sexual
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Physical
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Emotional
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Neglect
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Seen Someone Injured or Die
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If Yes, Describe
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SUBSTANCE USE HISTORY
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Have you ever used tobacco
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Nicotine - Age at first use
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Describe - Duration
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Tobacco Amount
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Do you drink alcoholic beverages
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Alcohol - Age of First Use
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Describe - Duration
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Alcoholic Beverages Amount
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Do you drink caffeine beverages
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Caffeine - Age at first use
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Describe - Duration
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Caffeinated Beverages Amount
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Rate Your Risk for HIV
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Risk for STD or Hepatitis
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Experienced Problems With
• • •
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SUBSTANCE USE INFORMATION
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Marijuana - Age at first use
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Marijuana - How often
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Cocaine/Crack - Age at first use
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Cocaine/Crack - How often
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Hallucinogen - Age at first use
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Hallucinogen - How often
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Heroin - Age at first use
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Heroin - How often
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Opioids - Age at first use
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Opioids - How often
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Meth - Age at first use
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Meth - How often
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Methamphetamines- Age-first use
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Methamphetamines- How often
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Amphetamines - Age at first use
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Amphetamines - How often
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Prescription meds- Age-first use
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Prescription meds - How often
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Other Drug - Age at first use
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Other Drug - How often
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Treatment for Addiction
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Reactions to Treatment Received
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Self-help groups - AA
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Self-help groups - Al-non
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Self-help groups - NA
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Substance Abuse Tx LOC
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Affc'td by alcohol use- Fam Mem
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Fam mem alcohol use affc'td most
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Affected by drug use- Family mem
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Fam mem drug use affected most
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PATIENT’S MENTAL HEALTH STATUS
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Patient Sleep
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Sleep - How many hours
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Hard to fall asleep
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Sleep - # of wake up
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Hard to get back to sleep
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Appetite/Dietary Habits
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Appetite/Dietary
• • •
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Appetite/Dietary Habits Duration
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Appetite/Dietary Comments
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Energy Level - Usual
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Energy Level - Today
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Energy Level - Past 3 Months
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Libido
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Sexually Active
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Practice Safe Sex
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Safe Sex Method
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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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Reliability-Clinician Perception
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Appearance
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Appearance - Other
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Personal Hygiene
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Personal Hygiene - Other
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Clothing
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Clothing (Describe if striking)
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Behavior
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Change during interview (describ
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Attentiveness
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Eye Contact
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Speech
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Psycho Motor
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Affect
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Patient Mood
• • •
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Perceptual Disturbances
• • •
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Perceptual Disturbances Comment
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Thought Processes
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Thought Content
• • •
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Memory
• • •
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Memory Comment
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Ability to Concentrate
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Emotional
• • •
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Intellect
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Patient Orientation to
• • •
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Insight
• • •
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Judgement
• • •
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Support Systems - Family
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Support Systems - Friends
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Support Systems - Other
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CRISIS & RISK ASSESSMENT
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Crisis Asmt 1 (low) - 10 (high)
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Risk Asmt 1 (low) - 10 (high)
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Risk to Harm Self
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Risk of Harm to Others
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Given Crisis Number
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Crisis Plan Necessary
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Patient's Strengths
• • •
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Patient's Challenges
• • •
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SUMMARY - Patient Issues
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SUMMARY - Recommendations
|
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Narrative
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