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Psychiatric History
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Currently in Psychotherapy?
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Current Therapy provider
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Previous psychiatric diagnosis
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Past psych hx comment
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Past psychiatric or psychotherapeutic practitioners
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Past psychiatric medications
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Trauma and/or abuse?
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Trauma/abuse comment
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Previous psychiatric hospitaization
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Previous psych hosp comment
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Previous substance use rehabilitation
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Rehab comment
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Previous suicide attempts
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Previous suicide attempt details
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Previous self harm behaviors
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Previous Self Harm behaviors details
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Previous violent behaviors
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Previous violent behaviors details
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Pertinent Medical History
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Have a PCP
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PCP Contact Information
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Other specialists seen regularly
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Current/Chronic Conditions
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Current/chronic disorder comments
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History of Head trauma
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Head/Brain Injury Comments
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History of seizures
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Seizure history Comment
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Bariatric Surgery
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Bariatric surgery Comments
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Particular diet?
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Getting 5 fruits and veggies per day?
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Daily caffeine intake
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Daily sugar intake
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Pregnancy considerations
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Birth Control considerations
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Intent to become pregnant soon?
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Pertinent family medical history
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Pertinent medical FHx details
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Family Psychiatric History
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Family members with
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Depression
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Comments
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Anxiety disorder
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Comments
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Mood disorder
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Comments
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Psychotic disorder
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Comments
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Substance use
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Comments
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Autism Spectrum
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Comments
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ADHD
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Comments
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Social History
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Born, Raised
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Current location
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Living Arrangements
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Marital Status
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Marital Status Comments
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Children
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Highest level of education
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Current occupation
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Spirituality/Religion
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Gender identity
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Sexual orientation
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Legal issues
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Legal issue comments
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Substance Use
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Alcohol frequency
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Alcohol amount
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Comments
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Marijuana
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Marijuana amount and method
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Comments
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Tobacco
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Comments
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Opioids
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Comments
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Amphetamines
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Comments
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Cocaine/Crack/other stimulant
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Comments
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Benzodiazepines
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Comments
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Hallucinogens
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Comments
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Other substances
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Comments
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