Initial Psychiatric Assessment Page 2
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5NAME/MRN
Psychiatric History (include hospitalizations and dates, suicide attempts, history of intervention):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Psychiatric Medication History (Current and Past, side effects, adherences & outcomes)
Current:
None Past:
None
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Alcohol/ Drug Use History: (Check all appropriate and provide details.)
Unknown
No Current Substance Abuse
No Past Substance Abuse
Currently Clean & Sober for:
>3 Mos.
>1 Yr
Past
Present
Past
Present
Past
Present
Alcohol
Nicotine
Caffeine
Cocaine
Past
Present
Marijuana
Past
Present
Amphetamines
Past
Present
Past
Present
Past
Present
Past
Present
Opiates
Ecstasy
Hallucinogens
Past
Present
Past
Present
Past
Present
Sedatives
Inhalants
Energy Drinks
Past
Present
Other:
Specify: ______________________________________________________
____________________________________________________________________________________________
Medical History (include illnesses, surgeries, CNS, head injuries):
Date of Last Physical: _______________
Physician(s)/clinic: _________________ Phone #: _______________
Weight: _____________ Height: _____________ BMI: _____________
Allergies (Meds & Other) / Adverse Reaction: ______________________________________________________
Active Medical Concerns, History of Hospitalizations/Surgeries: ________________________________________
Non-Psych Med/OTC __________________________________________________________________________
Review of Systems:
No Significant issues revealed
CV
Renal
GI
Hepatic
CNS
GU
Metabolic
CA
PULM
Gyn
ID/HIV
Sexually Active
Contraceptive Method _______________
Risk of Pregnancy
Pregnant
Breast-Feeding
LMP: _____________
Pregnancy and Birth History (<18):__________________________________________________________________________
Developmental History (<18): ______________________________________________________________________________
MHC113Initial Psychiatric Assessment (9/13)
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