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CHIEF COMPLAINT
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HISTORY OF PRESENT ILLNESS
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Suicidal Ideation
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Suicidal ideation comment
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PAST PSYCHIATRIC HISTORY
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Past Psychiatric History
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Suicide attempts/history of violence
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Hospitalizations
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Trauma history
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Family Psychiatric History
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Past medication trials
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Past medication
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MEDICATIONS
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Current therapist
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Social History
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Marital Status
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Ethnicity
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Highest level of education
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Employment
• • •
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Occupation
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Income
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Housing
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Lives with
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Children
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Relationships
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Upbringing
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Military
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Legal history
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Comments
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Substance Use History
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Substance use history
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Substance use comment
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Substance use disorder treatment
• • •
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Substance use treatment comments
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Caffeine
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Family History
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Past Medical History
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Past Medical History
• • •
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PMH comments
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Surgical History
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Primary care physician
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Specialists
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Family Medical History
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Mental Status Exam
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Sensorium*
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Appearance
• • •
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Concentration
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Detail Memory**
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Impulse control
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Behavior
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Movement
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Speech
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Mood*
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Affect
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Anxiety
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Depression
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Mania
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Sleep
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Appetite
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Obsessive-Compulsive symptoms
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ADHD symptoms
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Eating Disorder symptoms
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PTSD symptoms
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Thought process*
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Thought content*
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Hallucinations
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Delusions
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Insight*
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Judgment*
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Stressors
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Stressors comment
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Medical ROS (2-9DET, >10COMP)
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HEENT: WNL
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HEENT Comment
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Neuro/Endocrine: WNL
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Neuro/Endocrine comment
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CV: WNL
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CV comment
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Resp: WNL
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Resp comment
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GI: WNL
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GI comment
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Hematologic/Lymphatic: WNL
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Hematologic/Lymphatic comment
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Allergic/Immunologic: WNL
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Allergic/Immunologic comment
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Derm: WNL
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Derm comment
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Musculoskeletal: WNL
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Musculoskeletal comment
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Uro/GYN
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Medical ROS Comments
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Assessment
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Treatment Plan
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Patient Education
• • •
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