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Presenting Problem
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Patient's Report of Symptoms
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Mood
• • •
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Comments about Mood
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Anxiety
• • •
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Comments about anxiety
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Thought
• • •
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Comments about thought
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Behavior
• • •
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Comments about behavior
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Sleep
• • •
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Comments about Sleep
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Appetite
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Psychiatric History
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Psychiatric history description
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Current Meds
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Past Meds
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Prior Outpatient TX
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Prior Inpatient/Hospitalization
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History of Dangerous Behaviors
• • •
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Comments about dangerous behavio
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Family Mental Health
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Medical History
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Medical Conditions/Illnesses
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Meds
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Surgeries/Hospitalizations
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Disabilities
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Disability Comments
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CD History
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Prior or Current Tx
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Comments on CD tx
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Overdoses/DUI
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Comments on DUI/Overdoses
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Substance Use Risk Assessments
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Risk Assessment
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Suicidality
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Suicide Scale
• • •
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Homicidality
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Comments on Homicidality
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Abuse Assessment
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Comments about current abuse
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Eating Disorder Assessment
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Comments about Eating Disorders
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Reports to Authorities Required
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Social/Relational Factors
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Current Significant Rx
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Early Developmental hx
• • •
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Notes on development
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Child/Adolescent History
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School age social
• • •
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School age school
• • •
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Puberty
• • •
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Psychosexual
• • •
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Dating and peer relationships
• • •
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Adolescent School performance
• • •
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Adult Social/Peer rx
• • •
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Work hx
• • •
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Current Job and satisfaction
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Military hx
• • •
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Legal Hx
• • •
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Legal notes
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Social Relationships
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Cultural/Ethnic Factors
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Spiritual/Religious
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Education
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Leisure/Self Care
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Therapists Observations
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Appearance
• • •
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Dress
• • •
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Motor Activity
• • •
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Memory
• • •
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Attention/Concentration
• • •
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Thought Content
• • •
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Type of Delusions
• • •
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Thought Process/Flow of Thought
• • •
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Fund of Information
• • •
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Perception
• • •
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Insight
• • •
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Judgment
• • •
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Affect
• • •
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Behavior/Attitude
• • •
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Mood
• • •
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Speech
• • •
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Orientation
• • •
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Additional Obs of Children/Adol
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Physical Development
• • •
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Intellectional Development
• • •
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Language Development
• • •
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Social Development
• • •
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Activity Level
• • •
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Abuse
• • •
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Goals/Desired Changes
• • •
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DSM IV Diagnosis
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Axis I
• • •
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Axis II
• • •
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Axis III Medical Conditions
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Axis IV
• • •
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Axis V (GAF)
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GAF Descriptor
• • •
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