|
Past psych hx
|
|
|
Out-pt hx
|
Psycho-educational/Neuro-psych testing
|
|
In-pt Tx
|
Suicide hx
|
|
Violence hx
|
SIB
|
|
Current Psychiatric Medications
|
Past psych meds
|
|
|
|
|
Sub Ab hx
|
|
|
Adult: no use
|
|
|
Substance abuse:
|
Youth: no use
|
|
Detox
|
Current substance abuse treatment
|
|
Past substance abuse treatment
|
Sub ab tx comments
|
|
|
|
|
Med hx
|
No past med
|
|
Allergies
|
PE and labs
|
|
Past hospitalizations
|
Past medical history
|
|
Periods/menarche
|
Past surgeries
|
|
Head injury
|
Seizures
|
|
Vitamins
|
Non-psychiatric medications
|
|
|
Herbs/supplements
|
|
Fam med/psych hx
|
|
|
Mental Health
|
Suicide
|
|
Substance abuse
|
|
|
Medical
|
|
|
Arrhythmias
|
Sudden cardiac death
|
|
|
|
|
Dev hx
|
Developmental history:
|
|
Pregnancy
• • •
|
Comments
|
|
Peri-natal
• • •
|
Comments
|
|
Infancy
• • •
|
Comments
|
|
Toddlerhood neg
|
Toddlerhood
|
|
Separation
|
Potty Training
|
|
Day care
|
Discipline
|
|
Loss
|
Moves
|
|
Abuse (n/e/p/s)
|
|
|
|
|
|
Social History
|
Social History
|
|
Family Composition
|
Friends
|
|
Relationships
|
Interests/hobbies/fun
|
|
Occupation
|
Media (>2 hours/d)
|
|
Culture
|
Spirituality/religion
|
|
|
|
|
Educational history
|
|
|
Special education/accommodation(s)
|
Educational History
|
|
K
|
Elementary
|
|
Middle school
|
High school
|
|
College
|
Post graduate school(s)
|
|
Occupational school(s)
|
|
|
|
|
|
Criminal History
|
Criminal history
|
