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Psychiatric History
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How did you hear about us? (not included in note)
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Previous psychiatric care provider(s):
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Previous psychiatric diagnoses:
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Past psychiatric medication history:
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Psych hospitalization(s) and/or outpatient treatment programs:
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Comments:
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History of self harming behaviors
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Comments
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Previous suicide attempt
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Comments
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Does patient have access to firearms or other weapons in the home?
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Comments
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Violent outbursts or agression
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Comments
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Traumatic Life Events/General Comments:
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Family Psychiatric History:
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Substance Use History:
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Substance abuse history:
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Comments
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Alcohol use?:
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Comments
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Smoking/Vaping history?:
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Comments
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Developmental History:
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Issues with pregnancy & birth
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Comments
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Growth & Development
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Comments
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Accommodations in school
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Comments
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Social HX- Relationship status, children, whom patient lives with, etc.:
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Occupation:
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Spirituality:
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Level of Education:
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Hobbies and/or exercise:
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History of abuse
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Comments:
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Legal History:
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Comments:
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Sexual History
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Sexuality
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Sexually Active
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Comments
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Problems with sexual functioning:
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Comments:
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Past Medical & Surgical History:
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Past Medical History
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Surgical History
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Immunizations/Vaccinations:
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**Pertinent Family Medical History:
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Optional: Any family history of sudden cardiac deaths at a young age, neurological disorders, or seizure disorders? (use macros)
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