Scribd
Upload
237 views3 pages

Fig psychiatricAssessmentForm

The psychiatric assessment form collects information about a patient's history and current presentation. It includes sections on identifying information, history of present illness, psychiatric history, medical history, mental status examination, diagnosis, and treatment plan. The goal is to understand factors contributing to the patient's condition and determine an appropriate course of action.

Uploaded by

Patricia Eunise Heraña
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
237 views3 pages

Fig psychiatricAssessmentForm

The psychiatric assessment form collects information about a patient's history and current presentation. It includes sections on identifying information, history of present illness, psychiatric history, medical history, mental status examination, diagnosis, and treatment plan. The goal is to understand factors contributing to the patient's condition and determine an appropriate course of action.

Uploaded by

Patricia Eunise Heraña
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

Psychiatric assessment form

1. ID Name: ______________________________________ Sex:________________________________________ DOB:_____________________ Age:______________ 2. HPI ONSET, DURATION, COURSE (Why present now/precipitants/stressors? Impact on life) Marital status:________________________________ Occupation:__________________________________ Financial situation:_____________________________

When it started?

How long it lasts/frequency?

What is it like?

For episodic illnesses describe first episode: 1. Onset: 2. Precipitants: 3. Duration: 4. Rx response: DEPRESSION (Sigecaps) Low mood for >2 weeks Sleep Interest Guilt/worthlessness Energy Concentration Appetite/weight Psychomotor slowing Suicide: Hopelessness/Plan/Access GENERALIZED ANXIETY Excess worry Restless/edgy Easily fatigued Muscle tension sleep concentration SOCIAL PHOBIA Performance situations: Fear of embarrassment Fear of humiliation Criticism SPECIFIC PHOBIAS Heights/crowds/animals BODY DYSMORPHIC DISORDER Excess concern with appearance or certain part of body Avoidance behavior MANIA (Giddiness) Grandiose Increased activity goal-directed/high risk Decreased judgment Distractible Irritability Need less sleep Elevated mood Speedy talking Speedy thoughts PSYCHOSIS Hallucinations/illusions Delusions Self-reference: people watching you talking about you messages from media Thought blocking/insertion Disorganization: speech/behavior PANIC ATTACKS Trembling Palpitations Nausea/chills Choking/chest pain Sweating Fear: dying/going crazy Anticipatory anxiety Avoidance Agoraphobia

OBSESSIVE-COMPULSIVE DISORDER Intrusive/persistent thoughts Recognized as excessive/irrational Repetitive behaviors: Washing/cleaning Counting/checking Organizing/praying BORDERLINE PESONALITY Fear abandonment/rejection Unstable relationships Chronic emptiness self esteem Intense anger/outbursts Self-damaging behavior Labile mood and impulsivity EATING DISORDERS Binging/purging/restriction/amenorrhea Perception of body image or weight

PTSD Experienced/witness event Persistent re-experiencing Dreams/flashbacks Avoidance behavior Hyper-arousal: vigilance/ startle ANTISOCIAL PERSONALITY Forensic history: arrests/imprisonment Aggressiveness/violence Lack of empathy/remorse Lack of concern for safety: self or others Childhood conduct disorder

3. PSYCHIATRIC HX Previous psychiatric Hx/Counseling/Suicide attempts/Violence:

Previous diagnoses:

Medications/Tx:

4. FAM PSYCHIATRIC HX Psychiatric Dx/Visits/Counseling/Suicide attempts:

Substance use:

Suicide:

5. MEDICAL HX Previous illnesses & treatment:

6. SYSTEMS REVIEW CNS:

Surgeries/hospitalizations:

H & N:

CVS: Head injury (+/- LOC) and workup/imaging: RESP: Medications: GI:

Alcohol use:

GU:

Substance use: (caffeine, nicotine, over-counter/illicit med/drugs)

MSK:

DERM:

7. PERSONAL HX Place of birth: 10. IMPRESSION/FORMULATION BIOPSYCHOSOCIAL

As a child: (family structure, parents occupations, relationship with parents, siblings, friends, abuse)

As a teen: (friends, relationships, school, activities, sex, trouble, relationship with parents)

11. MULTIAXIAL DIAGNOSIS As an adult: (work, finances, education, relationships, family, goals for future, trends in functioning) Axis I: Psychiatric disorder:

8. MSE Axis II: Personality: Appearance: Behavior: Axis III: Medical conditions: Speech: Emotion: Affect and mood Axis IV: Social factors: Perception: Thought process: 12. PLAN Thought content: Investigations: Concentration: Memory: Treatment: Insight: Biological: Judgment: Suicide: Psychological:

9. FOLSTEIN MMSE Orientation: Time: year season month date day Place: floor building city province country Immediate recall: Attention: Delay recall: Naming: Repetition: 3-stage command: Reading: Copying: Writing: Total: /3 /5 /3 /2 /1 /3 /1 /1 /1 /30 /10

You might also like