Psychiatric History (Page 2 of 2) in pdf

Current or Chronic Illnesses:

__________________________________________________________________________________________________

Please list current medications and doses including over the counter medications and herbs and vitamins:

__________________________________________________________________________________________________

Allergies and reaction ________________________________________________________________________________

Do you use tobacco products and if so how much?_________________________________________________________

How often and what kind of caffeinated beverages do you use? ______________________________________________

How many beer, glasses of wine, mixed drinks, shots do you typically have in an average week?

__________________________________________________________________________________________________

Have you ever felt that you need to cut down on your drinking? YES NO

Have people criticized your drinking? YES NO

Have you ever felt guilty about your drinking? YES NO

Have you ever felt a need to have a drink in the morning to steady your nerves? YES NO

Have you ever had a DWI? YES NO

Do you smoke marijuana or use any other drugs and how often? _____________________________________________

Are you currently involved in any legal problems? YES NO Please explain if answered yes:

__________________________________________________________________________________________________

Social History:

Where did you grow up and explain your family of origin (parents, siblings) and briefly describe your childhood:

__________________________________________________________________________________________________

Have you been a victim of abuse? YES NO

__________________________________________________________________________________________________

Current Living situation: ______________________________________________________________________________

Do you feel safe in your current living situation? YES NO __________________________________________________

Marital History and number and ages of children if applicable_________________________________________________

Education and current employment______________________________________________________________________

Current support systems_______________________________________________________________________________

Please list any additional information that you think I should know or that you would like to discuss at today’s visit.

What are your goals for psychiatric treatment?

11/13/2009

Psychiatric History Page 2