Psychiatry
Loading Add to Favorites
Share
Tweet
Cite
Adult Medical History
[checklist name="Q1" value="Not Applicable|Abortion|Alcoholism|Anemia|Arthritis|Asthma|Brain Injury|Cancer, NOS|Chronic Pain|constipation|COPD|Crohn's Disease|Dental Disorders|Dizziness|Diabetes Mellitus|Drug Dependence|Emphysema|Epilepsy|Fatigue|Fibromyalgia|Hepatitis|Hypertension|HIV Infection|Irritable Bowel Syndrome|Motor Neuron Disease|Obesity|Renal Disease|Shingles|Sleep Disorder|STD|Stroke/CVA|Tuberculosis|Thyroid Disorders"]
[text]

Childhood Medical History
[checklist name="Q2" value="Not Applicable|Chicken Pox|Ear Infections|Ear Tubes|Eating Disorder|Encopresis|Enuresis|Measles|Mononucleosis|Mumps|Polio|Rheumatic Fever|Rubella|Scarlet Fever|Smallpox|Whooping Cough"]
[text]

Trauma History
[text]

Childhood Abuse
[checklist name="Q38" value="Verbally|Physically|Sexually|Physical neglect|Cultural deprivation|Subjected to ethnic discrimination"]

Treatment History
[text]

Substance Abuse History
[text]

Family Medical History
[checklist name="Q17" value="Alcholism|Drug dependence|Anxiety Disorder NOS|Depression|Mental (Psychiatric) Disorder|Suicide Completion|Family history of ADHD|Asthma|Cancer, NOS|Coronary artery disease|Diabetes mellitus|Heart disease|Hypertension|Seizure disorder|Thyroid disorder"]
[text]

Family History
[checklist name="Q17" value="Mental disability|Recorded family history of mental illness (not retardation)|Previous psychiatric treatment|Parents divorced"]
Mother
[text] Age
[select name="Q18" value="Alive|Deceased"]
Father
[text] Age
[select name="Q19" value="Alive|Deceased"]
[text] # Siblings born
Patient is [text default="youngest, oldest, middle, etc."]
Family history of alcoholism
[select name="Q20" value="Father|Mother|Both parents"]
[checklist name="Q21" value="Death in the family"]
[text]

Current Family and Significant Relationships
[checklist name="Q22" value="Living environment secure and supportive|Lack of social support from family|Lack of social support from friends|Lack of companionship|Interpersonal problems|Family problems|Family problems - Disruption|Family problems - Estrangement|Family problems - Physically or sexually abused by family member|ETOH use affecting relationships with others|Drug use affecting personal relationships"]
[text]

Social History
[checklist name="Q23" value="Living independently with spouse|Living with parents|Living with significant other"]
Spouse
[text] Age
[select name="Q24" value="Alive|Deceased"]
[text] # Children living
[text] # Children deceased
[checklist name="Q25" value="Single|Unmarried, living together|Recent breakup with significant other|Currently married"]
[text] # Total number of marriages
[checklist name="Q26" value="Separated"]
[checklist name="Q27" value="Divorced"]
[text] # Divorced times
[checklist name="Q28" value="Recently divorced"]
[checklist name="Q29" value="Widowed"]
[checklist name="Q30" value="Annulment"]
[text]

Assessment of current relationship (if applicable)
[checklist name="Q31" value="Interpersonal relationship problems"]
Life circumstance event
[checklist name="Q32" value="Physically abused"]
[checklist name="Q33" value="Sexually abused"]
[checklist name="Q34" value="Abused as child"]
[checklist name="Q35" value="Verbally berated, harassed, intimidated"]
[checklist name="Q36" value="Neglected as child "]
[checklist name="Q37" value="Abuse/neglect"]
[text]

Dangerousness Assessment
[checklist name="Q39" value="Previous suicide attempt|Suicidal ideation|Suicidal plan|Suicidal intent|Homicidal ideation|Homicidal plan|Homicidal intent|Repetitive self injurious|Access to weapons/guns in home"]
Adult Medical History



Childhood Medical History



Trauma History


Childhood Abuse


Treatment History


Substance Abuse History


Family Medical History



Family History

Mother
Age

Father
Age

# Siblings born
Patient is
Family history of alcoholism




Current Family and Significant Relationships



Social History

Spouse
Age

# Children living
# Children deceased

# Total number of marriages


# Divorced times





Assessment of current relationship (if applicable)

Life circumstance event








Dangerousness Assessment

Result - Copy and paste this output: