Psychiatry & Psychology
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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**
SUMMARY


PRESENTING SYMPTOMS


PAST PSYCHIATRIC HISTORY
Hospitalizations?
Past meds
Med compliance
OP treatment
Past SI/HI/AVH
Violence



PAST MEDICAL HISTORY
Seizures?
Head injury w/LOC?
Surgical history
Medications
Allergies
Pregnant?



SUBSTANCE USE
Tobacco:
Alcohol:
Drugs:
Rehab:
Other:

DEVELOPMENTAL HISTORY
Place of birth:
Raised by:
Parents (living/deceased, occupations, relationships):
Siblings (living/deceased, occupations, relationships):
Other important relationships:
Birth trauma:
Early Development:

SOCIAL HISTORY
Marital status:
Children:
Relationships:
Current living situation:
Sexual orientation:
Gender assigned at birth:
Employment:
Education:
Military:
Disability:
Legal:
Spiritual:
Guns:

**Interview and Examination performed by Jaci Yeager (MS4), University of the Incarnate Word SOM**

Result - Copy and paste this output:
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