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MEDICAL HISTORY
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Past Medical History
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Other:
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PCP
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Additional providers
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PAST PSYCHIATRIC HISTORY
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Prior Psychiatric Diagnosis
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Prior Psychiatric Treatment (mental / substance)
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Psychiatric History Includes
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Describe
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Patient Hospitalized
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Hospitalized
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Patient Hospitalised For
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Past Medication Trials
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FAMILY PSYCHATRIC HISTORY
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Paternal - Family Member Diagnos
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Maternal - Family Member Diagnos
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Sibling - Diagnos
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Free text other family mental health
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CLIENT'S DEVELOPMENTAL HISTORY
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Development
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Development
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Parents Married
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Parents divorce
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Birth order
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DV in home
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Client Raised by
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Close with family of origin
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Descibe
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SOCIAL HISTORY
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Marital Status
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Client Relationship History
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Initmate partner
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DV in the home
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Client's Children
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Descibe
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Sexual Orientation(s)
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Client's Sexual Status
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Living Arrangements
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Occupation
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Patient Employment Status
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Highest level of education
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Spiritual/Cultural Belief System
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Support System Community
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Support Systems - Friends
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Support Systems - Family
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TRAUMA & ABUSE HISTORY
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Childhood abuse or trauma
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Adult abuse or trauma
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Sexual
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Physical
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Emotional
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Neglect
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Ever been in an accident
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Seen someone injured or die
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Trauma details
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LEGAL HISTORY (Explain if Necess
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Ever Arrested
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Ever Convicted
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Current Legal Problems
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Describe
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SUBSTANCE USE INFORMATION
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Substance use history
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Patient is currently using substances
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Alcohol - Age at first use
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Alcohol - Most recent use
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Alcohol - How often
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Alcohol - How Admin
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Caffeine - Most recent use
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Caffeine - How often
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Caffeine - How Admin
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Marijuana - Age at first use
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Marijuana - Most recent use
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Marijuana - How often
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Marijuana - How admin
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Cocaine/Crack - Age at first use
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Cocaine/Crack - Most recent use
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Cocaine/Crack - How often
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Cocaine/Crack - How admin
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Hallucinogen - Age at first use
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Hallucinogen - Most recent use
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Hallucinogen - How often
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Hallucinogen - How admin
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Heroin - Age at first use
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Heroin - Most recent use
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Heroin - How often
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Heroin - How admin
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Opioids - Age at first use
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Opioids - Most recent use
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Opioids - How often
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Opioids - How admin
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Meth - Age at first use
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Meth - Most recent use
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Meth - How often
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Meth - How admin
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Methamphetamines- Age-first use
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Methamphetamines-Most recent use
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Methamphetamines- How often
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Methamphetamines- How admin
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Amphetamines - Age at first use
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Amphetamines - Most recent use
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Amphetamines - How often
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Amphetamines - How admin
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Prescription meds- Age-first use
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Prescription med-Most recent use
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Prescription meds - How often
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Prescription meds - How admin
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Nicotine - Age at first use
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Nicotine - Most recent use
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Nicotine - How often
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Nicotine - How admin
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Other Abuse Comments
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Substance Abuse Treatment
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Types and reactions to treatment
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Substance Abuse Details
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Other addictions
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Other Addictions
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Descibe
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