Initial Psychiatric Assessment Page 3

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NAME/MRN
Family Psychiatric History:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Psychosocial History (e.g. education, family, vocational, military, legal):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Psychosocial Risk Factors: (Check all that apply.) Document details.
Victim of Physical Abuse
History of Self-injurious Behavior
Victim of Sexual Abuse
History of Suicidal Behavior
Trauma or Loss in the Family
Family History of Suicide
Domestic Violence:
Victim
Perpetrator
Access to Firearms (family, friends, self)
History of Substance Abuse
Access to Other Means of Suicide
History of Assaultive Behavior
Lack of Social Support
History of Threatening Behavior
History of Foster Care
History of Inappropriate Sexual Behavior
Homelessness
Behavior Influences by Delusions or Hallucinations
Other
Comments:
MENTAL STATUS EXAMINATION
APPEARANCE/GROOMING
Unremarkable
Remarkable for:
PSYCHO-MOTOR ACTIVITY
Unremarkable
Remarkable for:
ATTITUDE/RELATEDNESS
Unremarkable
Remarkable for:
SPEECH
Unremarkable
Remarkable for:
MOOD
Unremarkable
Remarkable for:
AFFECT
Unremarkable
Remarkable for:
THOUGHT PROCESS
Unremarkable
Remarkable for:
THOUGHT CONTENT
Unremarkable
Remarkable for:
PERCEPTUAL DISTURBANCE
Unremarkable
Remarkable for:
ORIENTATION
Unremarkable
Remarkable for:
MEMORY/CONCENTRATION
Unremarkable
Remarkable for:
FUND OF KNOWLEDGE
Unremarkable
Remarkable for:
INTELLECT/ABSTRACT THINKING
Unremarkable
Remarkable for:
INSIGHT/ JUDGEMENT
Unremarkable
Remarkable for:
IMPULSE CONTROL
Unremarkable
Remarkable for:
Additional Observations: ________________________________________________________________________________
MHC113Initial Psychiatric Assessment (9/13)
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