Patient Name * First Name Last Name Date Of Birth * MM DD YYYY Age * Email * Occupation * Who do you live with * Do you feel safe * Yes No Psychiatric Diagnosis * 1) PRESENT ILLNESS * What emotional and/or medical issues have you been having recently? a . Depression? Have you felt sad for at least 2 weeks in the past month? * Yes No i. How is your Mood? * ii. How is your Sleep? * Good Fair Poor * It takes more than 30 min to fall asleep I wake up several times at night, and it’s hard to fall back asleep I wake up too early iii. How is your Interest in activities or hobbies? * Good Fair Poor iv. Do you feel Guilty about any of your past or present actions? * No Yes v. How is your Energy or Activity level? * Normal Increased Decreased vi. How is your Concentration? * Good Fair Poor vii. How is your Appetite? * No Change Increased Decreased viii. Current weight / Height / BMI / Weight change in past 2 months * ix. Have you had any thoughts of hurting yourself or others? * No Yes x. Would you act on this suicide/homicide plan? * No Yes xi. What would prevent you from acting on this plan? * xii. Do you have access to weapons? * No Yes xiii. Is there any Family History of suicide or homicide? * No Yes xiv. Have you ever attempted suicide/homicide? * No Yes b. Have you ever felt like your mind was hard to slow down or that thoughts were coming too quickly? No Yes * Trouble falling asleep because of racing thoughts Mood swings Feel I am better than others Hard for mind/body to relax Easily distractible, leave tasks undone Bad temper Have gone several nights without sleeping Have spent money excessively Have gotten into trouble with the law Have used drugs or excessive alcohol Are you impulsive Do people tell you that you sometimes don’t have a filter on what you say c. Psychosis: Have you ever heard voices, seen things or felt things that other people did not? * No Yes d. Anxiety * No Yes Have you had any of the following symptoms when anxious or nervous? * Fear of dying Palpitations Nausea/Chills Excessive worry Choking/Chest pain Sweating Fear of being in a crowd Avoiding things e. Obsessive-Compulsive Thoughts or Actions: * No Yes * Thoughts or Actions that recur even when you don’t want them to Repetitive behaviors such as washing your hands excessively, counting things excessively, checking locks excessively, hoarding items f. History of Trauma or Abuse? * No Yes * You experienced a traumatic event You have dreams/flashbacks of that event 2) PAST PSYCHIATRIC HISTORY a. Previous diagnosis and when? * Psychiatric Hospitalizations? * No Yes b. Any Psychiatric Medications in the past or present? * No Yes o Anti-anxiety * Valium Clonazepam Ativan Xanax Temazepam Buspar Hydroxyzine o Antidepressants * Fluoxetine Paroxetine Sertraline Cipralex Stablon Duloxetine Viibryd Trintellix Wellbutrin Nortriptyline Valdoxan Imipramine Mirtazapine Effexor Reboxetine Clomipramine o Antipsychotics/Mood Stabilizers * Quetiapine Risperidone Olanzapine Aripiprazole Geodon Fanapt Invega Saphris Rexulti Haldol Thorazine Clozaril Depakote Lithium Tegretol Lamictal Topamax Latuda o Sleep Aids * Trazodone Ambien Sonata Lunesta Belsomra Rozerem Melatonin o Stimulants * Elvanse Adderall Concerta Straterta Vyvanse Ritalin Focalin 3) PAST MEDICAL/SURGICAL HISTORY * Cancer Diabetes Migraines Surgeries Heart Attack Hypertension Seizures Stroke Asthma 4) FAMILY PSYCHIATRIC / MEDICAL HISTORY Depression ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, * Bipolar Disorder ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Schizophrenia ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Alcoholism/ Drug Abuse ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Suicide ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Anxiety ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Heart Disease ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Diabetes ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Cancer ( Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * Developmental Disorder (Father, Mother, Brother, Sister, Child, Maternal Grandparent,Paternal Grandparent, Uncle/Aunt/Cousin) * 5) SOCIAL HISTORY * Education Occupation * Relationship with family * Good Fair Poor Childhood * Good Fair Poor Abusive Marital Status * Married Single Divorced Widowed How many marriages: * Children * Daughter Son Friends/Support system: How Many * Exercise * Nutrition * Good Fair Poor Hobbies: * 6) SUBSTANCE USE a. Alcohol Use * b. Tobacco Use * c. Recreational Drugs * d. Prescription Pain Medications * e. Have you been in drug rehab/AA/NA? * No Yes Other 7) CURRENT MEDICATIONS * Medication Name ( Dose Strength, Dose Frequency, Medication Name, Dose Strength, Dose Frequency) 8) ALLERGIES * 9) OTHER * PATIENT HEALTH QUESTIONNAIRE AND GENERAL ANXIETY DISORDER (PHQ-9 and GAD-7) Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things. * Not at all Several days More than half the days Nearly every day 2. Feeling down, depressed, or hopeless. * Not at all Several days More than half the days Nearly every day 3. Trouble falling or staying asleep, or sleeping too much. * Not at all Several days More than half the days Nearly every day 4. Feeling tired or having little energy. * Not at all Several days More than half the days Nearly every day 5. Poor appetite or overeating. * Not at all Several days More than half the days Nearly every day 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down. * Not at all Several days More than half the days Nearly every day 7. Trouble concentrating on things, such as reading the newspaper or watching television. * Not at all Several days More than half the days Nearly every day 8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. * Not at all Several days More than half the days Nearly every day 9. Thoughts that you would be better off dead, or of hurting yourself in some way. * Not at all Several days More than half the days Nearly every day you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very Difficult Extremely Difficult Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Feeling nervous, anxious, or on edge. * Not at all sure Several days Over half the days Nearly every day 2. Not being able to stop or control worrying. * Not at all sure Several days Over half the days Nearly every day 3. Worrying too much about different things. * Not at all sure Several days Over half the days Nearly every day 4. Trouble relaxing. * Not at all sure Several days Over half the days Nearly every day 5. Being so restless that it’s hard to sit still. * Not at all sure Several days Over half the days Nearly every day 6. Becoming easily annoyed or irritable. * Not at all sure Several days Over half the days Nearly every day 7. Feeling afraid as if something awful might happen. * Not at all sure Several days Over half the days Nearly every day If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very Difficult Extremely Difficult Thanks for submitting the form! Your information has been received. Psychosocial Assessment
