|
History
|
|
|
Sources of Information
|
|
|
Patient is Source of Information
|
Patient is Source of Information Comments
|
|
Other Individual(s) Source of Information
• • •
|
Name of Source of Information Individual
|
|
Other Source of Information Comments
|
|
|
Inpatient Psychiatric History
|
|
|
Inpatient Psychiatric History?
|
Inpatient Psychiatric History Description
|
|
Outpatient Psychiatric History
|
|
|
Outpatient Psychiatric History?
|
Outpatient Psychiatric History Description
|
|
Suicide/Self-Harm History
|
|
|
Have you ever tried to harm or kill yourself?
|
Was your intent to die?
|
|
How many times in your life has this occurred?
• • •
|
Suicide/Self-Harm Elaboration
|
|
Violence History Assessment
|
|
|
Have you had any history of violent behavior?
|
Violent History Elaboration
|
|
Past Medical History
|
|
|
Do you have a history of any of the following health problems?
• • •
|
Other Health Problems
|
|
No Health Problems
|
|
|
Have you a history of surgery in any of the following areas?
• • •
|
Other Surgery(s)
|
|
No Surgeries
|
|
|
Psychiatric Medical History
|
|
|
Have you ever taken any medication for psychiatric treatment?
|
Psychiatric Medications
|
|
Patient Allergies
|
|
|
Do you have any known allergies to medication?
|
|
|
Medication Allergies
|
Allergic Reaction to Medication Allergies
|
|
Additional Medication Allergies
|
Additional Allergic Reaction to Medication Allergies
|
|
Additional Medication Allergies
|
Additional Allergic Reaction to Medication Allergies
|
|
Current Medications
|
|
|
Are you taking any medications currently? (Excluding medications for psychiatric treatment)
|
|
|
Medication
|
Dosage
|
|
Sig
|
Prescriber
|
|
Additional Medication
|
Dosage
|
|
Sig
|
Prescriber
|
|
Additional Medication
|
Dosage
|
|
Sig
|
Prescriber
|
|
Additional Medication
|
Dosage
|
|
Sig
|
Prescriber
|
|
Additional Medication
|
Dosage
|
|
Sig
|
Prescriber
|
|
Family Psychiatric History
|
|
|
Do you have any family members with a history of psychiatric illness?
|
|
|
Family Member with Psychiatric Illness
|
Family Psychiatric Problems
• • •
|
|
Additional Family Member with Psychiatric Illness
|
Family Psychiatric Problems
• • •
|
|
Additional Family Member with Psychiatric Illness
|
Family Psychiatric Problems
• • •
|
|
Additional Family Member with Psychiatric Illness
|
Family Psychiatric Problems
• • •
|
|
Additional Family Member with Psychiatric Illness
|
Family Psychiatric Problems
• • •
|
|
Family Medical History
|
|
|
Pertinent Family Medical History
|
|
|
Developmental and Educational History
|
|
|
During your pregnancy/birth, did your mother have any problems with any of the following:
• • •
|
Other Mother Pregnancy/Birth Problem
|
|
Did you have any complications after your birth?
• • •
|
Other Newborn Complications
|
|
Did you have any delays or difficulties in reaching the following developmental milestones?
• • •
|
Other Milestone Delay
|
|
Which options below best describe your childhood home atmosphere?
• • •
|
Other Home Atmosphere Description
|
|
Which of the following challenges were experienced during your childhood?
• • •
|
Other Childhood Challenges
|
|
Which of the following best describe problems you may have had in school?
• • •
|
Other School Problems
|
|
Did you have additional schooling outside of the standard classroom setting?
• • •
|
Other Additional Schooling
|
|
Highest Level of Education
|
|
|
General Social History
|
|
|
Which options below best describes your social situation?
• • •
|
Other Social Network
|
|
What is your current marital status?
|
What is the status of your intimate relationship?
|
|
What is the satisfaction level of your intimate relationship?
|
What is your sexual orientation?
|
|
What is your current living situation?
|
Who do you currently live with?
• • •
|
|
Do you currently participate in spiritual activities?
|
What is your current occupation status?
|
|
What is your current yearly income?
|
|
|
Longest Period of Employment
|
|
|
Start Date of Period of Continuous Employment
|
End Date of Period of Continuous Employment
|
|
Description of Period of Continuous Employment
|
Patient has never been employed
|
|
Menstruation and Pregnancy History
|
|
|
At what age did you begin menstruation?
|
Which of these best describe your premenstrual symptoms?
• • •
|
|
Do you have a method of contraception?
• • •
|
Other Methods of Contraception
|
|
Have you ever been pregnant?
|
How many times have you been pregnant?
|
|
Have you ever given birth?
|
How many times have you given birth?
|
|
Have you had any miscarriages?
|
How many times have you miscarried?
|
|
Have you had any abortions?
|
How many times have you had an abortion?
|
