Chief complaint:
HPI:
Onset
Sleep
Appetite
Energy
Anxiety
Concen/Mem
Hallucinations
Delusions
Agitation/Irrit.
Stressor
SI/HI/Self inj.
Past Psych Hx:
Hospitalization? Y/N
Therapist?
Meds MH?
Duration
Phx/when?Affect on fnx? Relief
ROS:
Plan?/Intent?/Access?
Dates? Length?
Dose?
How long?
Helpful?
S/E?
Trauma? Phsyc./emot.
SI Hx
When?
Substance Abuse Hx:
ETOH:
Cigarettes
Medications
Self-cope or recreational use?
Current/past
Quant.
Frequency/last time
LSD/HEROIN/LAXATIVES/COCAINE
Caffeine
HUFFING PAINT
Family Psych Hx:
MHx?
?
Social Hx: How long?
S/M
Children
Living situation
Safety concerns
Employment
Daily activities
Emotional support
Education
Financial
Legal charges
Who?
Substance?
Suicide?
Medical Hx?
Last time seen
Labs elec. Thyroid, b12
Medical conditions
Med/vit/suppl.
Birth control/pregn/BF/plan to get preg
Allergies
Tx?
Mental Status Exam:
Appearance: Groomed, frail, disheveled
Speech: Clear, pressured, soft, monotone
Mood/Affect: Approp. Dep. Anx. Labile. Ang.
Thought: Coh. Loose. Tang. Circum. Disorg.
Content of thought:
Hallucinations:
Delusions:
Muscle strg/tone:
Gait:
Suicidal:
Homicidal:
Orientation:
Judgment: Good. Fair. Poor
Memory rec: Good. Fair. Poor
Memory remote: Good. Fair. Poor
Attention/conc: Good. Fair. Poor
Language: Good. Fair. Poor
Fund of knowledge: Good. Fair. Poor