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Psychiatric History
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Psychiatric History Details
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Treatment With Medication
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Treatment with Counseling
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Treatment Comments
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Family Psychiatric History
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Father Psychiatric History
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Father Comments
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Paternal Psychiatric Family History
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Paternal Family History of Suicide or Suicide Attempts
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Suicide or Suicide Attempts Comments
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Paternal History of Drug or Alcohol Abuse
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Drug or Alcohol Abuse Comments
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Mother Psychiatric History
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Mother Comments
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Maternal Psychiatric Family History
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Maternal Family History of Suicide or Suicide Attempts
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Suicide or Suicide Attempts Comments
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Maternal Family History of Drug or Alcohol Abuse
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Drug or Alcohol Abuse Comments
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Siblings Psychiatric History
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Siblings Comment
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Social History
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Social History
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Marital Status
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Comments
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No. of Children
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Children: Name, Age
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Step-Children
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Single Parent
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Living Arrangements
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Parent, Sibling or other Family Comments
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Work History
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Military History
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Schooling
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Schooling Comments
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Hobbies/ Activities
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Legal History
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Comments
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Medical History
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Past Medical History
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Past Medical History Comment
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Surgeries
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Past Surgeries Comment
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Childhood Illnesses
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Childhood Illnesses Comment
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Physical Trauma
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Physical Trauma Comments
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Significant family medical history
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Traumatic Birth Event
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Women's Health
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Women Only
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Menarche
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Menstrual Status
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Last menstrual period
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Period frequency
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Menstrual Flow
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Pelvic Pain
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Birth Control
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PCOS symptoms
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PMS symptoms
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Pregnancy History
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Other:
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Caffeine, Drug and Alcohol Use
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Caffeine
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Caffeine Comment
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Tobacco
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Tobacco Comment
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Alcohol
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Alcohol Comment
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Drug
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Drugs Comment
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Pattern of Drug Use
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Social and Developmental History
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Early Developmental History (0-3
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Intrafamilial Relationships
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Social History
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School Performance
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Puberty
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Dating & Peer relationships
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Psychosexual
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Childhood Trauma
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Development Comments
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Sleep
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Patient sleeps
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Patient describes sleep as
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Recent Changes in Sleep
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Other comments
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Religious Preference
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Religious Affiliation
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Comments
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