Psych – New Patient/Initial Intake History

SUMMARY
[textarea name="1liner" default="_ is a _ year old _ with a history of _ currently treated with _______ who presents for initial evaluation and treatment ________."]  

PRESENTING SYMPTOMS
[textarea name="sx" default="Patient reports current symptoms of ___.  These symptoms have been going on since ___. They decided to seek treatment because/following ___."]
 
PAST PSYCHIATRIC HISTORY
[comment memo="Hospitalizations? 
	Past meds
	Med compliance
	OP treatment
	Past SI/HI/AVH
        Violence"]
[textarea name="psychhx" default="Patient was diagnosed with ___ in ____(year). (Describe precipitating events.) Pt reports/denies previous hospitalizations _(details). Pt has been treated in the past with _(rx)___ with __ effects. Pt reports/denies a history of SI/HI/AVH."]

PAST MEDICAL HISTORY
[comment memo="Seizures?
	Head injury w/LOC?
	Surgical history
	Medications
	Allergies
	Pregnant?"]
[textarea name="PMH" default="Pt has a pertinent PMH of ____. Patient is allergic to _/denies known allergies to medications."]

SUBSTANCE USE
Tobacco:[textarea name="Tobacco" default="Denies" rows="1"]
Alcohol:[textarea name="Alcohol" default="Denies" rows="1"]
Drugs:[textarea name="Drugs" default="Denies" rows="1"]
Rehab:[textarea name="Rehab" default="Not asked" rows="1"]
Other:[textarea name="Other" default="Not asked" rows="1"]

DEVELOPMENTAL HISTORY
Place of birth:[textarea name="Born" default="Not asked" rows="1"]
Raised by:[textarea name="Raised" default="Not asked" rows="1"]
Parents (living/deceased, occupations, relationships):[textarea name="Parents" default="Not asked" rows="1"]
Siblings (living/deceased, occupations, relationships):[textarea name="Siblings" default="Not asked" rows="1"]
Other important relationships:[textarea name="relationships" default="Not asked" rows="1"]
Birth trauma:[textarea name="birthtrauma" default="Not asked" rows="1"]
Early Development:[textarea name="earlydev" default="Not asked" rows="1"]

SOCIAL HISTORY
Marital status:[textarea name="Marital" default="Not asked" rows="1"]
Children:[textarea name="children" default="Not asked" rows="1"]
Relationships:[textarea name="rltnships" default="Not asked" rows="1"]
Current living situation:[textarea name="living" default="Not asked" rows="1"] 
Sexual orientation:[textarea name="sex" default="Not asked" rows="1"] 
Gender assigned at birth:[textarea name="gender" default="Not asked" rows="1"] 
Employment:[textarea name="job" default="Not asked" rows="1"] 
Education:[textarea name="school" default="Not asked" rows="1"] 
Military:[textarea name="military" default="Not asked" rows="1"] 
Disability:[textarea name="disability" default="Not asked" rows="1"] 
Legal:[textarea name="legal" default="Not asked" rows="1"] 
Spiritual:[textarea name="religion" default="Not asked" rows="1"] 
Guns:[textarea name="guns" default="Not asked" rows="1"]
	
**Interview and Examination performed by Jaci Yeager (MS4), University of the Incarnate Word SOM**