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Psychiatric Intake and Evaluation
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Consent to use AI Scribe? (to record and transcribe notes during the visit)
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Start and Stop Time
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IDENTIFYING INFORMATION:
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Reason for Visit:
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History of Presenting Illness:
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Symptoms in the Last 30 Days:
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CURRENT PROVIDERS:
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PCP (Primary Medical Provider)
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PCP Contact Information:
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Specialists
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Therapist/Counselor
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PAST PSYCHIATRIC HISTORY:
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Source of Information:
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Psychiatric History Includes:
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Past Mental Health Providers:
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Detailed Psychiatric History-Starting with Onset of Mental Health Symptoms:
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MEDICAL HISTORY
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MEDICAL HISTORY:
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POLST Status
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POLST Specify
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Age at First Period: (females only)
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Last Menstrual Period: (females only)
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Pregnancy History: (females only)
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Breast Feeding: (females only)
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Onset of Menopause: (females only)
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PSYCHOSOCIAL HISTORY
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DEVELOPMENTAL HISTORY:
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Place of Birth:
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Family Biological/Adopt
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Adopted Age:
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Patient's # of Moves in Lifetime
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Birth History (Vaginal/C-Section, Full or Preterm, Complications):
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Parents Married
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Raised by Whom:
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# of Siblings:
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Siblings Name(s) and Age(s)
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First Sexual Encounter Age
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First Sexual Encounter Consensual
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Sexual Orientation(s)
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Currently Sexually Active:
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Past Sexually Active
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Further Details of Sexual Orientation:
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Additional Social History Narrative
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SPIRITUAL HISTORY
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SPIRITUAL HISTORY:
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Practice by Family
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Spiritual/Cultural Belief System
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Spiritual/Cultural Comments
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MARITAL HISTORY
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MARITAL HISTORY:
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Number of Marriages
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Children (names and age)
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EDUCATIONAL HISTORY
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EDUCATIONAL HISTORY:
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Last School Attended
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Highest Grade Completed
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Learning Disabilities
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Learning Disabilities Comments
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Special Education
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Special Education Comments
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College Training
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College Training Where
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Vocational Schooling
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Vocational Schooling Where
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Special Training
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Special Training Where
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MILITARY HISTORY
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MILITARY HISTORY:
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Military Service
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Military Service Branch
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Military Service Active Duty
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Military - Type of Discharge
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Military - Date of Discharge
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VOCATIONAL HISTORY
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VOCATIONAL HISTORY:
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Vocational History
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Current Employment History:
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Past Employment History
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LEGAL HISTORY
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LEGAL HISTORY:
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Legal History:
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TRAUMA & ABUSE HISTORY
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TRAUMA and ABUSE HISTORY:
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Trauma and Abuse History:
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SUBSTANCE USE HISTORY
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SUBSTANCE USE HISTORY:
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History of Substance Use:
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Substances Used:
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Details of Substance Use History:
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CAGE QUESTIONS
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Cut down on drinking?
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Annoyed by your drinking?
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Guilty feelings about drinking?
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Ever used an eye opener (hair of the dog)?
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Mental Status Exam
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Orientation
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Eye Contact
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Change during Interview (describe):
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Appearance
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Personal Hygiene
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Personal Hygiene Other
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Clothing
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Clothing (describe if striking)
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Behaviour
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Attitude
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Affect
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Speech
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Mood
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Memory
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Concentration
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Thought Processes
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Content of Thought
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Perceptual Disturbances
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Level of Intelligence
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Judgment & Insight
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Coordination
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Psychomotor Activity
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Reliability (Clinician Perception's)
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Interaction During Interview
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Neurovegetative Symptoms:
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Sleep - How Many Hours
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Insomnia:
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Hard to Fall Asleep
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Sleep - # of Wake Up
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Hard to Get Back to Sleep
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Appetite/Dietary Habits
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Nutritional Behaviors:
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Appetite/Dietary Habits Duration
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Appetite/Dietary Comments
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Energy Level - Today (____/10)
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Libido
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Support Systems:
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Support Systems - Family
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Support Systems - Friends
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Support System - Community
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Community Spiritual Leaders
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Community Professional Leaders
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CRISIS and RISK ASSESSMENT
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Suicidal/Homicidal
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Detail of Suicidality or Homicidality
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Crisis Assessment 1 (low) -10 (High)
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Risk Assessment 1 (low) -10 (High)
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Risk to Harm Self
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Risk to Harm to Others
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Given Crisis Number
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Patient Needs Crisis intervention
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Crisis Plan Necessary
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Patient's Challenges
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Patient's Strengths
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