Psychiatry
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[textarea name="variable_1" default="sample text"]
Family History
Family of Origin:
[select name="variable_1" value="Biological
|Adopted
|Other"]

--
- Place of Birth:
[textarea name="variable_1" default="pt is originally from "]
Mother
[radio name="variable_1" value="pts mother is still living"][text name="variable_1" default="- Age of Mother: "][radio name="variable_1" value="pt's mother is deceased"][text name="variable_1" default="cause of death:"]
[text name="variable_1" default="- Prenatal (Illness, drug use, stressors of pt's mother):"]
Father
[radio name="variable_1" value="pts Father is still living"][text name="variable_1" default="- Age of Father: "][radio name="variable_1" value="pt's Father is deceased"][text name="variable_1" default="cause of death:"]
Significant Illnesses/Disease Of Parents:
[select name="variable_1" value="yes
|no"]
[text name="variable_1" default="yes, describe"]
[textarea name="variable_1" default=" Alcoholic/Drug Abusing Parent \n Parent Substance Use \n Depressed Parent \n Parent W/ Emotional Or Mental Health Problems "]
Parents' Marital Status
[select name="variable_1" value=""]
Relationship Quality:
[select name="variable_1" value="Cordial Relationship
Difficult Relationship
Enmeshed Relationship
Estranged
Strained Relationship
Hostile Relationship
Never Met
No Relationship
Present All Of Childhood
Present Part of Childhood"]
Siblings
Patient is
[select name="variable_1" value=" Middle Child
|Oldest Of Siblings
|Only Child
| Youngest Of Siblings"]
Has [text name="variable_1" default="#"]
Older And [text name="variable_1" default="#"] Younger Siblings
# of Brothers
[text name="variable_1" default="Living"]
[text name="variable_1" default="Deceased"]
# of Sisters
– Any Significant Illness/Disease Of Siblings:[select name="variable_1" value="yes
|no"][text name="variable_1" default="yes, describe"]
Additional Family Info:
[textarea name="variable_1" default="Grandparents\nAunts/Uncles/Cousins,\n Step Mother:\nStep Father:\nhalf siblings"]
Family Hx Of Mental Illness
[textarea name="variable_1" default="Family Hx Of Alcoholism \n Family Member Used Psychotropic Medications \n Family Member Hospitalized For Mental Health \n Family Member Had Outpatient Psychotherapy \n Family Members W/ History Of Mental Health Issues \n Previous Psych Tx In Family Members:"]
Pt Describes Childhood Household as
[select name="variable_1" value=" Outstanding Home Environment
Chaotic Home Environment
Household Dysfunction
Normal Home Environment"]
While growing up, Pt Reports:
[checkbox name="variable_1" value="Emotionally Abused: Verbally Berated, Harassed, Intimidated|Experienced Physical/Verbal/Sexual Abuse |Felt Neglected/Unloved|Financial Problems|Having An Unhappy Childhood|Lived In A Foster Home |Multiple Family Moves |Physically Abused|Sexually Abused|Violence In The Home|Witnessed Physical/Verbal/Sexual Abuse |Serious Medical Problems|Close Family Member Dying|Death In The Family|Family Concerns|Family Disruption|Family Estrangement|Family Member Diagnosed With Life-Threatening, Chronic Illness"]

[textarea name="variable_1" default=" Age And Circumstances Of Emancipation From Home:"]

[textarea name="variable_1" default="Relatives with mental illness:"]

Social Hx:
[textarea name="variable_1" default="Currently in a relationship that has lasted ?\nNot currently in a relationship.\nRecently out of a relationship that lasted ?"]

[textarea name="variable_1" default="Religious affiliations: ?\nCultural background: ?"]


[textarea name="variable_1" default="Does Not Smoke
Stopped Smoking
Currently Smokes Per Day
Does Not Drink
Currently Drinks
Occasionally\nEver Been In Treatment
What Did Use In Past
Currently Using Drugs
How Much
Notes
Denies Current Illicit Drug Use
Smoked Packs Cigarettes/Day X Years
Substance Abuse History
Reported Substance Abuse History
Reports Etoh Use
Reports Marijuana Use
Reports Heroin Use
Reports Cocaine Use
Reports Use
Amount Used
Duration Of Use
Precipitants
Attitude Toward Use
History Of Withdrawal
Longest Time Sober
Quit Tobacco Use In
Current Daily Alcohol Use
"]

[textarea name="variable_1" default="Does Exercise Regularly
Does Not Exercise Regularly
Does Not Sleep Well
Does Sleep Well
"]
[textarea name="variable_1" default="sample text"]
[textarea name="variable_1" default="sample text"]

Family History
Family of Origin:


--
- Place of Birth:

Mother


Father

Significant Illnesses/Disease Of Parents:



Parents' Marital Status

Relationship Quality:

Siblings
Patient is

Has
Older And Younger Siblings
# of Brothers


# of Sisters
– Any Significant Illness/Disease Of Siblings:
Additional Family Info:

Family Hx Of Mental Illness

Pt Describes Childhood Household as

While growing up, Pt Reports:






Social Hx:









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