Past History

Brief biography of patient: [textarea cols=80 rows=5 default="Brief Biography"]

Past psychiatric history: [textarea cols=80 rows=5 default="denied when asked"]

Past suicide attempts or serious incidents: [textarea cols=80 rows=5 default="denied when asked"]

Existing medical conditions: [textarea cols=80 rows=5 default="No reported medical conditions"] 

Drug and alcohol use: [textarea cols=80 rows=5 default="denied when asked"]

[link url="https://www.soapnote.org/mental-health/dast-10/" memo="drug use screening"] 

[link url="https://www.soapnote.org/mental-health/audit/" memo="alcohol use screening"] 

Forensic details and risk: 
[checkbox name="forensic" value="patient denied any forensic history when asked|patient has identified forensic risk|acts of violence|a criminal record|court-ordered sanctions are in place"]
[textarea cols=80 rows=5 default="no forensic risk details given"]

Details of family psychiatric history: 

[checkbox name="fampsych" value="patient's family has no significant psychiatric history|patient's family has a significant psychiatric history|schizophrenia|bipolar disorder|depression|anxiety|alcohol or substance abuse|attempted/completed suicide"]
[textarea cols=80 rows=5 default="no family psychiatric history details given"]

Family medical history: [textarea cols=80 rows=5 default="unable to report on family's medical history"]

Medication / Dose / Frequency: [textarea cols=80 rows=5 default="Nil"]

Allergies: [textarea cols=80 rows=5 default="nil known allergies"]

Other treatments: [textarea cols=80 rows=5 default="no other treatments identified"]

Developmental risk factors: [textarea cols=80 rows=5 default="childhood abuse denied when asked"]; [textarea cols=80 rows=5 default="Intellectual difficulties denied when asked"]; [textarea cols=80 rows=5 default="Nil vulnerabilities identified"]; [textarea cols=80 rows=5 default="No traumatic events identified"]

When I asked the patient about psychosocial and socioeconomic factors that may have impacted on their development and current functioning, they reported:

[checkbox name="Q1" value="There were difficulties related to their education and literacy:|There were no difficulties with their education and literacy."][conditional field="Q1" condition="(Q1).is('There were difficulties related to their education and literacy:')"] 
[conditional field="Q1" condition="(Q1).is('There were difficulties related to their education and literacy:')"][checkbox name="education" value="Z55.0 Illiteracy and low-level literacy|Z55.1 Schooling unavailable and unattainable|Z55.2 Failed examinations|Z55.3 Underachievement in school|Z55.4 Educational maladjustment and discord with teachers and classmates|Z55.8 Other problems related to education and literacy|Z55.9 Problem related to education and literacy, unspecified"]. [textarea cols=80 rows=5 default="dates of education difficulties and duration"][/conditional]

[checkbox name="Q2" value="There were difficulties related to their employment:|There were no difficulties with their employment."][conditional field="Q2" condition="(Q2).is('There were difficulties related to their employment:')"] 
[conditional field="Q2" condition="(Q2).is('There were difficulties related to their employment:')"][checkbox name="employment" value="Z56.0 Unemployment, unspecified|Z56.1 Change of job|Z56.2 Threat of job loss|Z56.3 Stressful work schedule|Z56.4 Discord with boss and workmates|Z56.5 Difficult conditions at work|Z56.6 Other physical and mental strain related to work|Z56.7 Other and unspecified problems related to employment"]. [textarea cols=80 rows=5 default="dates of employment difficulties and duration"][/conditional]

[checkbox name="Q3" value="There were difficulties related to hazzardous work conditions:|There were no difficulties with hazzardous work conditions."][conditional field="Q3" condition="(Q3).is('There were difficulties related to hazzardous work conditions:')"] 
[conditional field="Q3" condition="(Q3).is('There were difficulties related to hazzardous work conditions:')"][checkbox name="hazwork" value="Z57.0 Occupational exposure to noise|Z57.1 Occupational exposure to radiation|Z57.2 Occupational exposure to dust|Z57.3 Occupational exposure to other air contaminants|Z57.4 Occupational exposure to toxic agents in agriculture|Z57.5 Occupational exposure to toxic agents in other industries|Z57.6 Occupational exposure to extreme temperature|Z57.7 Occupational exposure to vibration|Z57.8 Occupational exposure to other risk-factors|Z57.9 Occupational exposure to unspecified risk-factor"]. [textarea cols=80 rows=5 default="dates of hazzardous work conditions and duration"][/conditional]

[checkbox name="Q4" value="There were difficulties related to environmental toxins:|There were no difficulties with environmental toxins."][conditional field="Q4" condition="(Q4).is('There were difficulties related to environmental toxins:')"] 
[conditional field="Q4" condition="(Q4).is('There were difficulties related to environmental toxins:')"][checkbox name="envitox" value="Z58.0 Exposure to noise|Z58.1 Exposure to air pollution|Z58.2 Exposure to water pollution|Z58.3 Exposure to soil pollution|Z58.4 Exposure to radiation|Z58.5 Exposure to other pollution|Z58.6 Inadequate drinking-water supply|Z58.7 Exposure to tobacco smoke|Z58.8 Other problems related to physical environment|Z58.9 Problem related to physical environment, unspecified"]. [textarea cols=80 rows=5 default="dates of exposure to environmental toxins and duration"][/conditional]

[checkbox name="Q5" value="There were difficulties related to housing and economic circumstances:|There were no difficulties with housing and economic circumstances."][conditional field="Q5" condition="(Q5).is('There were difficulties related to housing and economic circumstances:')"] 
[conditional field="Q5" condition="(Q5).is('There were difficulties related to housing and economic circumstances:')"][checkbox name="housing" value="Z59.0 Homelessness|Z59.1 Inadequate housing|Z59.2 Discord with neighbours, lodgers and landlord|Z59.3 Problems related to living in residential institution|Z59.4 Lack of adequate food|Z59.5 Extreme poverty|Z59.6 Low income|Z59.7 Insufficient social insurance and welfare support|Z59.8 Other problems related to housing and economic circumstances|Z59.9 Problem related to housing and economic circumstances, unspecified"]. [textarea cols=80 rows=5 default="dates of problems with housing and economic circumstances and duration"][/conditional]

[checkbox name="Q6" value="There were difficulties related to the social environment:|There were no difficulties with the social environment."][conditional field="Q6" condition="(Q6).is('There were difficulties related to the social environment:')"] 
[conditional field="Q6" condition="(Q6).is('There were difficulties related to the social environment:')"][checkbox name="socenvi" value="Z60.0 Problems of adjustment to life-cycle transitions|Z60.1 Atypical parenting situation|Z60.2 Living alone|Z60.3 Acculturation difficulty|Z60.4 Social exclusion and rejection|Z60.5 Target of perceived adverse discrimination and persecution|Z60.8 Other problems related to social environment|Z60.9 Problem related to social environment, unspecified"]. [textarea cols=80 rows=5 default="dates of problems with the social environment and duration"][/conditional]

[checkbox name="Q7" value="There were difficulties related to negative events in childhood:|There were no difficulties with negative events in childhood."][conditional field="Q7" condition="(Q7).is('There were difficulties related to negative events in childhood:')"] 
[conditional field="Q7" condition="(Q7).is('There were difficulties related to negative events in childhood:')"][checkbox name="childneg" value="Z61.0 Loss of love relationship in childhood|Z61.1 Removal from home in childhood|Z61.2 Altered pattern of family relationships in childhood|Z61.2 Altered pattern of family relationships in childhood|Z61.3 Events resulting in loss of self-esteem in childhood|Z61.4 Problems related to alleged sexual abuse of child by person within primary support group|Z61.5 Problems related to alleged sexual abuse of child by person outside primary support group|Z61.6 Problems related to alleged physical abuse of child|Z61.7 Personal frightening experience in childhood|Z61.9 Negative life event in childhood, unspecified"]. [textarea cols=80 rows=5 default="dates of problems with negative events in childhood and duration"][/conditional]

[checkbox name="Q8" value="There were difficulties related to parenting practices:|There were no difficulties with parenting practices."][conditional field="Q8" condition="(Q8).is('There were difficulties related to parenting practices:')"] 
[conditional field="Q8" condition="(Q8).is('There were difficulties related to parenting practices:')"][checkbox name="parprac" value="Z62.0 Inadequate parental supervision and control|Z62.1 Parental overprotection|Z62.2 Institutional upbringing|Z62.3 Hostility towards and scapegoating of child|Z62.4 Emotional neglect of child|Z62.5 Other problems related to neglect in upbringing|Z62.6 Inappropriate parental pressure and other abnormal qualities of upbringing|Z62.8 Other specified problems related to upbringing|Z62.9 Problem related to upbringing, unspecified"]. [textarea cols=80 rows=5 default="dates of problems with parenting practices and duration"][/conditional]

[checkbox name="Q9" value="There were difficulties related to the family:|There were no difficulties with the family."][conditional field="Q9" condition="(Q9).is('There were difficulties related to the family:')"] 
[conditional field="Q9" condition="(Q9).is('There were difficulties related to the family:')"][checkbox name="family" value="Z63.0 Problems in relationship with spouse or partner|Z63.1 Problems in relationship with parents and in-laws|Z63.2 Inadequate family support|Z63.3 Absence of family member|Z63.4 Disappearance and death of family member|Z63.6 Dependent relative needing care at home|Z63.7 Other stressful life events affecting family and household|Z63.8 Other specified problems related to primary support group|Z63.9 Problem related to primary support group, unspecified"]. [textarea cols=80 rows=5 default="dates of problems with the family and duration"][/conditional]

[checkbox name="Q10" value="There were other psychosocial difficulties:|There were no other psychosocial difficulties."][conditional field="Q10" condition="(Q10).is('There were other psychosocial difficulties:')"] 
[conditional field="Q10" condition="(Q10).is('There were other psychosocial difficulties:')"][checkbox name="psychdif" value="Z64.0 Problems related to unwanted pregnancy|Z64.1 Problems related to multiparity|Z64.2 Seeking and accepting physical, nutritional and chemical interventions known to be hazardous and harmful|Z64.3 Seeking and accepting behavioural and psychological interventions known to be hazardous and harmful|Z64.4 Discord with counsellors"]. [textarea cols=80 rows=5 default="dates of other psychosocial problems and duration"][/conditional]

[checkbox name="Q11" value="There were legal difficulties and / or problems related to armed conflict:|There were no legal and / or armed conflict difficulties."][conditional field="Q11" condition="(Q11).is('There were legal difficulties and / or problems related to armed conflict:')"] 
[conditional field="Q11" condition="(Q11).is('There were legal difficulties and / or problems related to armed conflict:')"][checkbox name="legarmed" value="Z65.0 Conviction in civil and criminal proceedings without imprisonment|Z65.1 Imprisonment and other incarceration|Z65.2 Problems related to release from prison|Z65.3 Problems related to other legal circumstances|Z65.4 Victim of crime and terrorism|Z65.5 Exposure to disaster, war and other hostilities|Z65.8 Other specified problems related to psychosocial circumstances|Z65.9 Problem related to unspecified psychosocial circumstances"]. [textarea cols=80 rows=5 default="dates of legal / armed conflict problems and duration"][/conditional]

Premorbid personality:
[textarea cols=80 rows=5 default="easygoing; Difficult; Slow-to-warm?"]

Patterns of self-regulation and impulsivity:
[textarea cols=80 rows=5 default="How does this patient self-regulate"]

Psychosexual history:
[textarea cols=80 rows=5 default="Unable to rate"]