Psychiatric History

Psychiatric HistoryPlease 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 OtherCage Screen:Have you ever thought you needed to cut down on your drinking/drug use?____Yes ____NoHave you ever been annoyed by other people’s criticism of your drinking/drug use?____Yes ____NoHave you ever felt guilty about your drinking/drug use?____Yes ____NoHave you ever used alcohol/drugs as an eye opener to get you going in the morning or to treat a hangover?____Yes ____NoSuicidal 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 ____NoIf suicide attempted, complete the chart below:Date Means Tried Pt Alone? Pt Sought Help? HospitalizedYes No Yes No Yes No ______Yes No Yes No Yes No ______Yes No Yes No Yes No ______Does the patient endorse relief at failing the attempt(s)? ____Yes ____NoDoes the patient currently endorse feeling hopeful that his/her problems will resolve w/o suicide? ____Yes ____NoCan patient currently endorse one or more reasons to live? ____Yes ____NoIs there a family history of suicide? ____Yes ____NoIf yes, who? ______Self-Injurious Behavior History:Does the patient have a history of self-mutilation or other forms of intentional self-injury? ____Yes ____NoIf 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 ____NoIf yes, specify:______Does the patient have a history of aggressive behavior (including bullying, threatening, intimidating, and/or destruction of property) ____Yes ____NoIf yes, specify:______Does the patient have a history of other antisocial behavior (including fire setting, lying, school truancy, theft) ____Yes ____NoIf yes, specify:______Criminal History:Does patient have a history of arrests: ____Yes ____NoIf yes, specify:______Does patient have a history of DUIs ____Yes ____NoIf yes, specify:______Does patient have pending legal charges? ____Yes ____NoIf yes, specify:______Probation/Parole? ____Yes ____NoIf yes, specify:______Trauma History: Rocky Mountain Psychiatry 303.750.2082 Type of Abuse Age at Onset Perpetrator DurationSexual ______Physical ______Emotional ______Neglect ______Verbal ______Other:Patient witnessed traumatic event(s)? ____Yes ____NoIf yes, specify:______Additonal traumatic events? ____Yes ____NoIf yes, specify:______Significant loses? ____Yes ____NoIf yes, specify:______Other personal significant life events? ____Yes ____NoIf yes, specify:______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 HistoryName 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 DoctorateOther 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 OtherSexuality: ____ Heterosexual ____Homosexual ____Bisexual ____Transsexual ____ Sexually InactiveContraception Yes No If yes,specify:______Sexual Dysfunction Yes No If yes,specify:______Marital StatusPrimary Relationship Status Duration Primary Relationship Status DurationLiving 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 HistoryPresent 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 earningsDo 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 othersFriends and Acquaintances:___Many acquaintances and close friends___Some acquaintances and few close friends___A few acquaintances and a few friends___Minimal acquaintances and friendsQuality of Relationships with Friends___Stable ___Distant ___Unstable ___Supportive ___Intense or rapidly changingDescribe 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

Psychiatric History

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