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Date: Assigned SW: Name: Contacts: Chief Complaint: Informants: Hpi

This document contains sections for collecting a patient's chief complaint, history of present illness, psychosocial history, past psychiatric and medical history, family history, social history, mental status exam, vital signs, lab results, assessment, diagnoses, and treatment plan. The document is used to comprehensively evaluate and document a patient's mental and physical health during a psychiatric evaluation.

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91 views2 pages

Date: Assigned SW: Name: Contacts: Chief Complaint: Informants: Hpi

This document contains sections for collecting a patient's chief complaint, history of present illness, psychosocial history, past psychiatric and medical history, family history, social history, mental status exam, vital signs, lab results, assessment, diagnoses, and treatment plan. The document is used to comprehensively evaluate and document a patient's mental and physical health during a psychiatric evaluation.

Uploaded by

alex
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Date: Assigned SW:

Name: Contacts:

Chief Complaint:
Informants:
HPI:

Hobbies/interests (anhedonia?):
Coping mechanisms/alleviating factors:
Goals:

Psych ROS:
Anyone out to get you/Phobias Caffeine Tobacco EtOH Drugs H/o substance
Mood Sleep Appetite/Weight Energy Concentration/Focus Memory
Depression Delusions Hallucinations HI/SI/self-harm/cutting Obsessions/Compulsions
Mania Anxiety/Worry/Panic Head injury Seizures Abuse/Trauma Pain

1.) Past Psychiatric History: 2.) Home Medications Inpatient Medications


Diagnoses:

Psychiatrist:
Therapist:
Other providers:
Past meds/tx:

Hospitalizations:

3.) Allergies 5.) Family History 6.) Social History:


Education:
4.) Past Medical History & Occupation:
Surgeries Military:
Living situation:
Support system:
Legal issues:
Mental Status Exam
Appearance Speech Mood & Affect

Thought Process Thought Content Perception


Delusions SI / self-harm / HI Hallucinations
Phobias Obsessions / Compulsions Illusions
Sensorium & Cognition Insight Judgment
A & O x ___ Addressed & stamped envelope on
Simple calc ground?
Immediate, recent, remote memory
Serial 7s or WORLD
Birds of a feather flock together

VS: Other Labs/Studies:


Urine tox Blood tox CBC

BMP TSH B12


Vitamin D

HIV Head CT UA
RPR

Assessment:

Diagnoses
Axis I:
Axis II/Personality Disorders/MR:
Axis III/General Medical Conditions:
Axis IV/Homelessness/Poor social support/Unemployment:
Axis V/GAF:

Plan:

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