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Appointment Time:
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PCP
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Specialists
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Therapists
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Other
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Medical/Surgical/Psychiatric History
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History:
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Allergies:
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TBI:
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TBI Comment:
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Seizure History:
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Seizure Comment:
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Contraception?
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Contraception Comment
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Females: Gravida/Para
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Current Medications:
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Past Medications:
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BDI Score:
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ACE Score:
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HAM-A Score:
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Prior Hospitalizations/ER Visits:
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Family Medical/Psychiatric History
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Family Medical History:
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Family Psychiatric History:
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Social History
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Born:
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Raised:
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Sibling Position:
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Parents Divorced:
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Divorce Impact:
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Living Situation Growing Up:
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Living Situation Presently:
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Family Relationship Status Presently
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Household member with mental illness (past/present)
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Household member with mental illness past/present comment:
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#Children
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# past committed relationships
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In a committed relationship?
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Experience of Friendship
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Highest Level Education & Degree Obtained
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Currently Student
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Currently Employed
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Occupation/Employer
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Spirituality/Religious practices
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Mindfulness/Awareness Training
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Community Involvement
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Hobbies
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Exercise
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nutrition habits
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Protective Factors
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Hours of Screen time daily?
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Current/Past Legal Issues
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Criminal History
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Criminal History Comment
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Substance Use Past/Present
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Caffeine:
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caffeine comment:
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Alcohol:
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alcohol comment:
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Nicotine
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nicotine comment:
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Cannabis
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cannabis comment:
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Cocaine:
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cocaine comment
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Psychedelics:
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psychedelics comment
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Crystal Meth
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crystal meth comment
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Methamphetamines
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methamphetamines comment
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Heroin
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heroin comment
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Opiates
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opiates comment
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Benzos
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Benzos comment
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Other substance use:
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other substance use comment
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PDMP Check
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PDMP Comment:
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Household Member with Substance Use (past/present)
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Household Member Active Substance Use Comment:
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Trauma History
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Exposure to Anger/Violence:
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Anger/Violence Comment
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Sexual Abuse:
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Sexual Abuse Comment
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Physical Abuse:
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Physical Abuse Comment
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Emotional/Verbal Abuse
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Emotional/Verbal Abuse Comment
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Feel safe at home?
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Safe at home comment
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Traumatic Injuries/Illnesses
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Traumatic Injuries/Illnesses Comment
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Chief Complaint
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chief complaint
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HPI
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HPI
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Medical/Psychiatric ROS:
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Medical Review of Systems:
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Depression Assessment
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Change from previous functioning?
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Impairment in Functioning?
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Hard to fall asleep
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Hard to get back to sleep
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Awaken during night?
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sleep comment
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Depressed mood?
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Anhedonia
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Fatigue or low energy?
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Decreased motivation?
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weight loss or gain?
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worthlessness or guilt?
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Concentration/Thinking/Indecisiveness issues?
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Duration of depression symptoms
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Depression Assessment Comment
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Suicidal/homicidal
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Suicidal/homicidal
• • •
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SI/HI comment
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Self Injurious Behaviors?
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Anxiety Assessment
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Excessive Anxiety/Worry?
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Excessive Anxiety/Worry Comment:
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Difficult to control worry?
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Restless?
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Easily Fatigued?
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Difficult Concentrating or mind going blank?
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Irritability?
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Muscle Tension?
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Symptoms cause distress or impairment?
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Duration of symptoms
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anxiety assessment comment
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PTSD Assesment
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Exposure to actual or threatened death?
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Exposure to actual/threatened serious injury?
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Exposure to actual/threatened sexual violence?
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Exposure details?
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Recurrent Intrusive Memories?
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Recurrent Distressing Dreams?
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Dissociative Reactions (flashbacks)?
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Intense/Prolonged Psychological Distress with Cues?
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Marked Phsyiological Reactions to Cues?
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Persistent avoidance of stimuli?
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Negative alterations in cognition?
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Hyperarousal?
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Exaggerated Startle Reflex?
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Length of symptoms
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PTSD Assessment Comment
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ADHD Assessment
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Inattention?
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Careless mistakes?
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Difficulty sustaining attention?
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Doesn't listen?
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Difficulty Following Through?
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Difficulty Organizing?
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Avoids sustained mental effort?
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Often loses things?
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Easily distracted?
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Forgetful?
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Fidgety/restless?
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Difficulty being still?
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Interrupts others?
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Duration of symptoms?
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ADHD Assessment Comment
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Bipolar Assessment
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Elevated or expansive mood?
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Irritable mood?
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Increased Goal-Directed Activity/Energy?
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Inflated self-esteem?
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Decreased need for sleep?
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More Talkative/Pressured Speech?
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Flight of Ideas/Racing Thoughts?
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Distractibility?
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Psychomotor agitation?
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Activities with painful consequences?
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Marked impairment in functioning?
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Symptoms observable by others?
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Duration of symptoms
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Bipolar Assessment Comment
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Psychosis Assessment
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Delusions?
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Auditory Hallucinations?
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Visual Hallucinations?
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Paranoia?
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Disorganized Speech?
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Disorganized or Catatonic behavior?
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Decreased Emotional Response to People/Events?
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Alogia?
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Unmotivated?
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Withdrawn?
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Unusual feelings?
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Unusual thoughts?
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Unusual Behaviors?
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Duration of symptoms?
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Psychosis Assesment Comment
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Mental Status Exam
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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 Personal 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 interv
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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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CRISIS & RISK ASSESSMENT
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Crisis Assessment 1 -10
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Risk Assessment 1 (low)-10 (High
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Risk to harm self
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Risk to harm to others
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Given Crisis Number
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Client Needs Crisis intervention
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Medical Decision Making
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Impression/Assessment
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Differential Diagnosis
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Meds/Labs/Education/Consents
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Plan
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Plan
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