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Assessment type
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Chief Complaint
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HPI:
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Other information:
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Today the patient/guardian states:
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Psychopharm Status
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Medication Side Effects
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Explain "other" side effects
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Current stressors
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Information provided by
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New Stressors in Patient's Life
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Depression Symptoms
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Anxiety Symptoms
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Mania Symptoms
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ADHD Symptoms
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Bipolar Symptoms:
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Organic Mental Disorder Symptoms
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Schizophrenia or Paranoid Sympto
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Substance Abuse Symptoms
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Eating Disorder Symptom
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Binge Eating Disorder Symptoms
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Location
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Location Comments
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Quality
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Quality Comments
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Severity
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Severity Comments
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Duration
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Duration Comments
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Onset / Timing
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Onset Comments
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Context
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Context Comments
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Modifying Factors
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Modifying Factors Comments
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Associated Symptoms
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Associated Symptoms Comments
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CLIENT’S MENTAL HEALTH STATUS
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Sleep
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Client Sleep
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Sleep - How many hours
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Sleep - # of wake up
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Hard to fall asleep
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Hard to get back to sleep
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Appetite/Dietary Habits
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Appetite/Dietary Habits
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Appetite/Dietary Habits Duration
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Appetite/Dietary
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Appetite/Dietary Comments
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Binge Eating Episodes, Time of Day, Location
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BEDS-7 Score
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Binge-Purge Episodes
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Restriction of Intake
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Libido
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Practice Safe Sex
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Sexually active
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Libido
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Suicidal/homicidal
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Suicidal/homicidal
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Reliability
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Reliability-Clinician perception
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Appearance
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Client Appearance:
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Client Appearance - Other
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Personal Hygiene
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Client Grooming and Hygiene:
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Client personal hygiene other
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Behavior
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Client Behaviour
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Clothing
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Client Clothing
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Clothing (Describe if striking)
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Attitude
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Client Attitude
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Eye Contact
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Client - Eye Contact
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Change during interview (describ
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Speech
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Client Speech
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Psycho motor Activity
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Client - Psycho motor Activity
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Interaction during interview
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Client Interaction during interview
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Other Client Interactions:
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Mood, Temperament & Emotional
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Emotional Range
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Client Emotional
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Client Mood
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Client Temperament
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Affect
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Client - Affect
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Perceptual disturbances
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Client - Perceptual disturbances
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Thought processes
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Client - Thought processes
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Content of thought
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Client Content of thought
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Information and intelligence
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Appropriate to age and education
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Orientation to
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Client Orientation to
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Able to concentrate
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Able to follow instructions
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Memory
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Client Memory
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Coordination
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Client Coordination
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Judgment & Insight
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Client Judgment & Insight
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Support Systems
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Support Systems - Family
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Support Systems - Friends
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Client's Strengths
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