Psychiatric Appointment Information Sheet
(To be filled out by family/service provider/case manager and brought to psychiatric appointment)
Patient Name
Psychiatric Prescriber
Person(s) Completing Form
Relationship to Patient
Guardian (if any)
Guardian phone #
Recent Weight & Date when weighed
Date of last Blood Draw
Appt. Date
Who else provided input?
Date of last visit
Pharmacy Name and Phone Number
Name(s) of other involved medical specialists (general practitioner, neurologist, gastroenterologist, dentist, therapist, etc.)
List all current psychiatric meds, dosages, & times administered.
List all current non-psychiatric meds, dosages, & times administered.
Current DSM Diagnosis (if any):
Axis I:
Axis II:
Axis III:
Describe other efforts to address symptoms of
concern:
How is the client doing in general?
Great
OK
Doing Poorly
Please address the following issue(s):
Since the last appt. is the client doing:
Better
Same
Worse
Stress Related To Life Events:
Check If New Or Continuing, Otherwise Leave Blank.
Stressful Event
New Continuing Please comment on significant
Start/change/loss of job
stresses noted:
Significant change in support staff
Victim of crime or assault
Move to a new residence
Death in family
Loss of preferred activity
Death or loss of a friend
Change in family circumstance
Increased stress at home
Exposed/witness to violence
Law enforcement contact
Change in physical health
Medical tests/MD visits/ER visits
Other -
Psychiatric Appointment Information Sheet – p. 2
Physiological Symptoms – Check if New or Continuing, otherwise leave it blank.
Symptom
Constipation
Nausea/Vomiting
Diarrhea
Rectal bleeding/discomfort
Abdominal pain
Weight gain/loss
Urinary difficulties/excess
Edema/swelling
Chest pains
Tingling/numbness
Dizziness/fainting
Slurred speech
Rapid or slow pulse
Stumbling/unsteady gait
Stiffness
Tremor/shaking/ticks
Seizures
Fatigue
Headache
Physical weakness
Injury requiring medical response
Other -
New
Cont.
Symptom
Unusual facial/mouth/eye movement
Unusual movements of extremities
Drooling
Dry mouth
Increased thirst
Unusual tastes/smells
Appetite change
Choking on food
Dental pain
Rash/Itching
Change in skin color
Breast discharge
Menstrual changes
Sexual function difficulties
Excessive sleepiness
Loud snoring
Breathing abnormalities
Wheezing or coughs
Sweating or chills
Hearing/vision changes
Hair loss/unusual growth
Other -
New
Cont.
Behavioral Symptoms – Check if New or Continuing, otherwise leave it blank.
Symptom
Anger outburst(s)
Assaultive behaviors
Property destruction
Listless. low energy
Crying, tearfulness
Increased sleep/time in bed
Isolative, withdrawn
Decreased interest in activities
Work/recreation activity refusals
Low response, flat affect, latent
SIB causing self harm
Talking about death/dying
Suicidal plans/behavior
Nightmares
Poor attention to hygiene
Excessive neediness/dependent
Making false accusations
Poor phone use (making 911 calls)
Has dangerous friends
Criminal activity
Substance abuse/misuse
New
Cont.
Symptom
Repeated police/ER contacts
Stripping/exposing self in public
Change in sexual activity
Labile, rapid change in mood
Dramatic reduction in need for sleep
Changes in food/drink intake
Restlessness or anxiety
Intrusive/pressured
Rapid speech
Disorganized/tangential speech
Hallucinations, psychotic symptoms
Possible delusions and/or paranoia
Peculiar rituals
Pacing/repetitive physical activity
Obsessively organized
Hoarding/stealing/collecting
Increased irritability
Elopement or wandering
Medication refusals/misuse
Missing psych/therapy appointments
Other:
New
Cont.