Psychiatric History

Please briefly describe the issues and problems with which you need help. Include obstacles to solving the problems. ______

How long have you had the problem or issue?______

In what ways is your family sympathetic or unsympathetic? ______

Have you had any recent stressful life events? ______Write anything you wish to tell about your life. You may include: Events that gave you joy or disappointment, educational goal/achievements, travel, books or people that influenced you. ______

Primary caregiver in childhood and adolescence Age Primary caregiver(s) Other living in home ______

Describe parental relationships during childhood and adolescence ______

Rocky Mountain Psychiatry 303.750.2082 Describe family relationships during childhood and adolescence ______

Describe your current relationships (include strengths and problems) with:

Spouse/Partner______

Spouse/Partner’s family______

Mother______

Father______

Children______

Siblings______

Rocky Mountain Psychiatry 303.750.2082 Substance Use History (check and complete for all that apply):

Drug Frequency/Amount Route of Duration Last Longest Administration Use Period clean/sober Caffeine Nicotine Alcohol Marijuana Barbiturates Heroin Cocaine Inhalants LSD PCP Designer Drugs Benzodiazepines Prescription Opiates Other

Cage Screen:

Have you ever thought you needed to cut down on your drinking/drug use?

____Yes ____No

Have you ever been annoyed by other people’s criticism of your drinking/drug use?

____Yes ____No

Have you ever felt guilty about your drinking/drug use?

____Yes ____No

Have you ever used alcohol/drugs as an eye opener to get you going in the morning or to treat a hangover?

____Yes ____No

Suicidal Risk Assessment:

Rocky Mountain Psychiatry 303.750.2082 ____No suicidal ideation ____Yes: suicidal ideation present (complete below)

Specify plan/intent:______

Does patient have the means to carry out the plan? ____Yes ____No

If suicide attempted, complete the chart below:

Date Means Tried Pt Alone? Pt Sought Help? Hospitalized

Yes No Yes No Yes No ______

Does the patient endorse relief at failing the attempt(s)? ____Yes ____No

Does the patient currently endorse feeling hopeful that his/her problems will resolve w/o suicide? ____Yes ____No

Can patient currently endorse one or more reasons to live? ____Yes ____No

Is there a family history of suicide? ____Yes ____No

If yes, who? ______

Self-Injurious Behavior History:

Does the patient have a history of self-mutilation or other forms of intentional self-injury? ____Yes ____No

If yes, specify the form of self-injurious behavior______

Date of last self-injury:______

Violence History Rocky Mountain Psychiatry 303.750.2082 Patient has a history of violent behavior (including fights, use of weapons, and/or cruelty to animals): ____Yes ____No

If yes, specify:______

Does the patient have a history of aggressive behavior (including bullying, threatening, intimidating, and/or destruction of property) ____Yes ____No

Does the patient have a history of other antisocial behavior (including fire setting, lying, school truancy, theft) ____Yes ____No

Criminal History:

Does patient have a history of arrests: ____Yes ____No

Does patient have a history of DUIs ____Yes ____No

Does patient have pending legal charges? ____Yes ____No

Probation/Parole? ____Yes ____No

Trauma History: Rocky Mountain Psychiatry 303.750.2082 Type of Abuse Age at Onset Perpetrator Duration

Sexual ______

Physical ______

Emotional ______

Neglect ______

Verbal ______

Other:

Patient witnessed traumatic event(s)? ____Yes ____No

Additonal traumatic events? ____Yes ____No

Significant loses? ____Yes ____No

Other personal significant life events? ____Yes ____No

Psychiatric History: Rocky Mountain Psychiatry 303.750.2082 Date of first psychiatric symptoms:______

Specify:______

Date of first psychiatric treatment:______

Inpatient treatment (Include any drug and/or alcohol rehab):

Location: (hospital, city) Dates of Admission Reason for Admission ______

Outpatient treatment (include drug/alcohol rehab and psychotherapy):

Location: (hospital, city) Dates of Admission Reason for Admission ______

Medication History

Name of Medication Dates of Treatment Benefits Side Effects ______

______

Family Psychiatric History: (M= maternal& P= paternal) Rocky Mountain Psychiatry 303.750.2082 Disorder List family member(s) with positive history for each disorder:

Alcoholism ______Personality Disorder ______

Drug Addiction______Suicide ______

Anxiety Disorder______Bipolar Disorder ______

Panic Disorder ______OCD ______

Schizophrenia ______PTSD ______

Depression ______ADHD ______

Dementia ______Other ______

Primary Caregivers in Childhood and Adolescence (Check all that apply):

____ Biological mother ____ Biological father ____ Stepfather

____ Stepmother ____ Adoptive mother ____ Adoptive father

____ Foster parents ____ Older sibling: M/F ____ Aunt/Uncle

____ Paternal grandmother ____ Paternal grandfather ____ Paternal grandfather

____ Maternal grandmother ____ Other:

Describe parental relationships during childhood and adolescence: ______

Developmental History:

Birth Problems ____No ___ Yes If yes, specify______

Developmental delays ____No ___ Yes If yes, specify______

Remarkable childhood illness ____No ___ Yes If yes, specify______

Head injuries ____No ___ Yes If yes, specify______Level of Education: Rocky Mountain Psychiatry 303.750.2082 Highest Level of Education Completed: GED High School College Masters Doctorate

Other Training:______

Are you currently registered in school? Yes No If yes, specify:______

Are you interested in furthering your education? Yes No If yes, specify:______

History of learning disability? Yes No If yes, specify:______

School Involvement:

Education Program: Regular Honors Special Ed Alternative Overall Grade Status: A/B Student C/D Student Failing Courses Conduct: Suspensions Detention Frequent Reprimands Activities: Sports Clubs Band/Choir Other

Sexuality: ____ Heterosexual ____Homosexual ____Bisexual ____Transsexual ____ Sexually Inactive

Contraception Yes No If yes,specify:______

Sexual Dysfunction Yes No If yes,specify:______

Marital Status

Primary Relationship Status Duration Primary Relationship Status Duration

Living with partner______Separated ______

Married ______Widowed ______

Never Married______Unmarried______

Divorced ______

Number of times married/divorced and dates: ______

Rocky Mountain Psychiatry 303.750.2082 Quality of primary relationship (circle all that apply): stable, unstable, supportive, unsupportive, distant, intense, rapidly changing, other______

If you are not together with someone, are you dating? ____Yes ____No If yes, specify:______

Work History

Present employment______How long in job?______

Describe what you do: ______

Longest job patient held:______

Frequent job changes? _____ Yes ____No If yes, explain______

List prior types of employment:______

Current Employment Status (Check all that apply):

___ Job earnings ___ Workman’s Comp ___ Temporary work disability

___ Unemployed ___ SSDI ___ SSI (pending/current)

___ Alimony ___Benefits ___ No source of income

___ Self employed ___ Charity donation ___ Significant other’s job earnings

Do you have difficulty managing finances? ___ Yes ___No If yes, specify:______

Family Structure (spouse/partner, children, parents, siblings, other significant people) Name/relationship Gender Age Financially Resides in Quality of dependent household relationship on patient? F M Yes No Yes No F M Yes No Yes No F M Yes No Yes No F M Yes No Yes No F M Yes No Yes No F M Yes No Yes No Please specify any difficulties in your family relationships: ______Social Relationships (check all that apply and comment on any items checked)

Rocky Mountain Psychiatry 303.750.2082 Social Feelings: ___Connected to others ___Inhibited or inadequate ___Comfortable alone ___Feelings of inferiority ___ Isolated ___Dependent on others approval ___Avoidant/uninvolved ___Controlling of others ___Lonely ___Judgmental/critical of others ___Alienated from community ___Fear of abandonment ___Suspicious of others

Friends and Acquaintances:

___Many acquaintances and close friends

___Some acquaintances and few close friends

___A few acquaintances and a few friends

___Minimal acquaintances and friends

Quality of Relationships with Friends

___Stable ___Distant ___Unstable ___Supportive ___Intense or rapidly changing

Describe quality of relationships: ______

Spiritual Beliefs of Affiliations ______Hobby and Leisure interests: Rocky Mountain Psychiatry 303.750.2082 ______

Community Service: ______

Military History: ______

Rocky Mountain Psychiatry 303.750.2082