|
Biopsychosocial Assessment
|
|
|
*Indicates required question
|
|
|
1. Your Name:
|
|
|
2. Today's Date:
|
|
|
3. Date of birth:
|
|
|
4. What brings you in to seek care with me at this time?
|
|
|
5. Are you seeking a medication evaluation, therapy, or both?
|
|
|
6. What goals do you have for your treatment?
|
|
|
|
|
|
7. What current symptoms are you experiencing? (select all that apply)
• • •
|
|
|
Other:
|
|
|
8. Have you experienced trauma?
|
|
|
9. Have you seen a mental health provider(s) previously?
|
|
|
10. If yes, please include the following information: Name of provider, time period, reason for changing:
|
|
|
11. Do you have a current therapist, counselor, or psychiatric provider? If yes, what is their name
|
|
|
12. Have you previously received a diagnosis from a mental health provider?
|
|
|
13. If yes, what were you diagnosed with?
|
|
|
14. What current and past psychiatric medications have you taken? Please list All current and past prescription medications and
|
|
|
15.Please describe any side effects or adverse effects you have experienced with medication(s):
|
|
|
16. Family Psychiatric history: Has anyone in your family every experienced any of the following?
• • •
|
|
|
17. If yes, who had each problem:
|
|
|
18. Has a family member ever been treated with a psychiatric mediation? If so, which medication and how effective was this treat
|
|
|
19. Have you ever misused or taken a prescription medication other than as prescribed?
|
|
|
20. Have you ever been treated for any substance misuse? If so, please describe (setting, dates of treatment, outcome)
|
|
|
21.How much caffeine do you ingest daily?
|
|
|
22. Do you drink alcohol? If so, how many occasions per week and how many drinks per occasion?
|
|
|
23. Do you use nicotine in any form (cigarettes, cigar, pipe, chewing tobacco, vape, nicotine patch or gum)?
|
|
|
24. Do you use any other substances?
|
|
|
25. Have you ever been admitted to a psychiatric hospital, and if so, why?
|
|
|
26. Have you ever attended an Intensive Outpatient or Partial Hospital Program? If so, when and where?
|
|
|
27. Do you have any religious or spiritual preferences or practices that you would like to mention?
|
|
