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IDENTIFYING INFORMATION
Patient Sex
Marital Status
Patient arrived with
Accompanied (By Whom)
Patient Living
Patient lives with whom explain
Patient Employment Status
Patient Living (Sponsor)
• • •
Physical Barriers to Treatment
Physical Barriers Comments
Specific Barriers to Treatment
Specific Barriers Others
Patient Current Medications
Medication Instruction
Patient Other Services
CURRENT PROVIDERS
PCP
Specialists
Therapists (Self)
Other
PAST PSYCHIATRIC HISTORY
Psychiatric History Includes
• • •
Patient Hospitalized
Patient Hospitalised Where
When patient hospitalised
Hospitalised Medications
Hospitalised
CLIENT'S MEDICAL HISTORY
Medical/Physical Problems
• • •
Any other medical problem
Patient's Surgical Procedures
Tests, Labs
Consultation for substance abuse
Patient's Dental Provider
Date of Last Dental Service
Patient's Disability
Identify Disability
Disability Compensation
Disability Compensation Comments
PATIENT FAMILY MEDICAL HISTORY
Family Medical History
• • •
Consultation for medical abuse
Paternal Family Mem Health Issue
Consultation for mental health
PATIENT FAMILY MENTAL HISTORY
Paternal - Family Member Diagnos
Paternal - Describe Treatment
Paternal - Describe Response
Paternal - Describe Medication
Paternal family health issue
Maternal - Family Member Diagnos
Maternal - Describe Response
Maternal - Describe Treatment
Maternal - Describe Medication
Maternal Family Mem Health Issue
CLIENT'S DEVELOPMENTAL HISTORY
Client's Place of Birth
Client's Family Biological/Adopt
Client Adopted Age
Client's # of Moves in Lifetime
Development
• • •
Development Explain
Client's Parents Married
Client Raised by (Parent)
Client's # of Siblings(Name(s)/A
Siblings (Name(s) and Age(s)
Client's Family Contact
Client's Sexual Status
Client First Sexual Encounter Ag
Was this consensual
Sexual Orientation(s)
• • •
SPIRITUAL HISTORY
Practice by Family
Spiritual/Cultural Belief System
Spiritual/Cultural Comments
CLIENT'S HISTORY
Client Marriage History
Client's Children (names and age
EDUCATIONAL HISTORY
Last School Attended
Learning Disabilities
Learning Disabilities Comments
Special Education
Special Education Comments
College Training
College Training Where
Vocational Schooling
Vocational Schooling Where
Special Training
Special Training Where
MILITARY SERVICE
Military Service
Military Service Branch
Military Service Active Duty
Military - Type of Discharge
Military - Date of Discharge
VOCATIONAL HISTORY
Vocational History
• • •
Current Employment
Current Employment Explain
Current Employment Duration
Past Employment
Past Employment Explain
Past Employment Duration
Reason for Leaving
LEGAL HISTORY (Explain if Necess
Ever Arrested
Ever Convicted
Current Legal Problems
• • •
TRAUMA & ABUSE HISTORY
Sexual
• • •
Describe- Nature of Relationship
Describe - Duration
Describe - Severity of Abuse
Physical
• • •
Describe- Nature of Relationship
Describe - Duration
Describe - Severity of Abuse
Emotional
• • •
Describe- Nature of Relationship
Describe - Duration
Describe - Severity of Abuse
Neglect
• • •
Describe- Nature of Relationship
Describe - Duration
Describe - Severity of Abuse
Ever been in an accident
Seen someone injured or die
Die or Injured Comments
SUBSTANCE USE HISTORY
Have you ever used tobacco
Do you use tobacco now
Tobacco Amount
Tobacco in what form
Do you drink alcoholic beverages
Alcoholic Beverages
• • •
Alcoholic Beverages Amount
Do you drink caffeine beverages
Caffeine Amount Daily
Treatment for Addiction
Have you ever used
• • •
Ever used street drugs
Ever used prescription Med
Do you now
Rate you risk for HIV
Risk for STD or Hepatitis
Experienced Problems With
• • •
Explain Experienced Problems
SUBSTANCE USE INFORMATION
Drug - Age at first use
Drug - Most recent use
Drug - How often
Drug - How Admin
Caffeine - Age at first use
Caffeine - Most recent use
Caffeine - How often
Caffeine - How Admin
Marijuana - Age at first use
Marijuana - Most recent use
Marijuana - How often
Marijuana - How admin
Cocaine/Crack - Age at first use
Cocaine/Crack - Most recent use
Cocaine/Crack - How often
Cocaine/Crack - How admin
Hallucinogen - Age at first use
Hallucinogen - Most recent use
Hallucinogen - How often
Hallucinogen - How admin
Heroin - Age at first use
Heroin - Most recent use
Heroin - How often
Heroin - How admin
Opioids - Age at first use
Opioids - Most recent use
Opioids - How often
Opioids - How admin
Meth - Age at first use
Meth - Most recent use
Meth - How often
Meth - How admin
Methamphetamines- Age-first use
Methamphetamines-Most recent use
Methamphetamines- How often
Methamphetamines- How admin
Amphetamines - Age at first use
Amphetamines - Most recent use
Amphetamines - How often
Amphetamines - How admin
Prescription meds- Age-first use
Prescription med-Most recent use
Prescription meds - How often
Prescription meds - How admin
Nicotine - Age at first use
Nicotine - Most recent use
Nicotine - How often
Nicotine - How admin
Other Abuse Comments
Substance Abuse Treatment
Substance Abuse Including
• • •
Reactions to Treatment Received
Experience with self-help groups
Self-help groups - AA
Self-help groups - NA
Self-help groups - Al-non
Affc'td by alcohol use- Fam Mem
Affc'td by alcohol use-Other Mem
Affected by drug use- Family mem
Affected by drug use- Other Mem
Fam mem alcohol use affc'td most
Oth mem alcohol use affc'td most
Fam mem drug use affected most
Other mem drug use affceted most
CLIENT’S MENTAL HEALTH STATUS
Client Sleep
• • •
Sleep
Sleep - How many hours
Sleep - # of wake up
Hard to fall asleep
Hard to get back to sleep
Appetite/Dietary Habits
Appetite/Dietary Habits
• • •
Appetite/Dietary Habits Duration
Appetite/Dietary
• • •
Appetite/Dietary Comments
Energy level
Energy level - Usual
Energy Level - Past 3 months
Energy Level - Today
Libido
Sexually active
Libido
• • •
Practice Safe Sex
Suicidal/homicidal
Suicidal/homicidal
• • •
Reliability
Reliability-Clinician perception
Appearance
Client Appearance
Client Appearance - Other
Personal Hygiene
Client Personal Hygiene
Client personal hygiene other
Behavior
Client Behaviour
• • •
Clothing
Client Clothing
Clothing (Describe if striking)
Attitude
Client Attitude
• • •
Eye Contact
Client - Eye Contact
Change during interview (describ
Speech
Client Speech
• • •
Psycho motor Activity
Client - Psycho motor Activity
Interaction during interview
Client Interaction during interv
• • •
Mood, Temperament & Emotional
Emotional Range
Client Emotional
• • •
Client Mood
• • •
Client Temperament
• • •
Affect
Client - Affect
• • •
Perceptual disturbances
Client - Perceptual disturbances
• • •
Thought processes
Client - Thought processes
• • •
Content of thought
Client Content of thought
• • •
Information and intelligence
Appropriate to age and education
Orientation to
Client Orientation to
• • •
Able to concentrate
Able to follow instructions
Memory
Client Memory
• • •
Coordination
Client Coordination
• • •
Judgment & Insight
Client Judgment & Insight
• • •
Support Systems
Support Systems - Family
Support System Community
Support Systems - Friends
Community Professional Leaders
Community Spiritual Leaders
What brings you here today
CRISIS & RISK ASSESSMENT
Client Personal Hygiene Other
Crisis Assessment 1 -10
Risk Assessment 1 (low)-10 (High
Risk to harm self
Risk to harm to others
Given Crisis Number
Client Needs Crisis intervention
Crisis plan necessary
Client's Strengths
• • •
Client's Challenges
• • •
SUMMARY - Client issues
SUMMARY - Any past services
SUMMARY - Recommendations
SUMMARY - Needs
FIVE AXIS DIAGNOSIS
Five axis diagnosis - #
Five axis diagnosis - Descriptio
Five axis diagnosis by history
By History - By whom
AXIS I
AXIS II
AXIS III
AXIS IV
AXIS V
GAF(CURRENT)
GAF (LAST YEAR)
AC-OK Screening for Co-Occurring
Adult: # of yes questions 1-7
Adult: # of yes questions 8-13
Adult: # of yes questions 14&15
Adolescent (Ages 10-20)
Adolescent - Questions 1-6
Adolescent - Questions 7-12
Adolescent - Questions 13-15
Stages for Primary DX
• • •
Client did not answer this time

Initial Assessment Medical Form

Psychiatrist

Initial Assessment

There are 1038 copies in use.
Published: Feb. 6, 2013, 2:11 p.m.
Doctor: Dr. History Physical
Rating: +47   /

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