Has any family member used psychotropic medications?

Name _________________ Patient ID _______ __ Patient SSN ___________ Date _________ Date of Birth _ __ _______ Page 1 Biopsychosocial History Presenting Problems Primary _____________________________________________________________________________________________ ______ Secondary _____________________________________________________________________________________________ ______ _____________________________________________________________________________________________ ______ Current Symptom Checklist (Rate intensity of symptoms currently present) Mild = Impacts quality of life, but no significant impairment of day - to - day functioning Moderate = Significant impact on quality of life and/or day - to - day functioning Severe = Profound impact on quality of life and/or day - to - day functioning Symptom Impact Symptom Impact None Mild Moderate Severe None Mild Moderate Severe Aggressive Behaviors ? ? ? ? Laxative/Diuretic Abuse ? ? ? ? Agitation ? ? ? ? Loose Associations ? ? ? ? Anorexia ? ? ? ? Mood Swings ? ? ? ? Appetite Disturbance ? ? ? ? Obsessions/Compulsions ? ? ? ? Bingeing/Purging ? ? ? ? Oppositional Behavior ? ? ? ? Circumstantial Symptoms ? ? ? ? Panic Attacks ? ? ? ? Concomitant Medical Condition ? ? ? ? Paranoid Ideation ? ? ? ? Conduct Problems ? ? ? ? Phobias ? ? ? ? Delusions ? ? ? ? Physical Trauma Perpetrator ? ? ? ? Depressed Mood ? ? ? ? Physical Trauma Victim ? ? ? ? Dissociative States ? ? ? ? Poor Concentration ? ? ? ? Elevated Mood ? ? ? ? Poor Grooming ? ? ? ? Elimination Disturbance ? ? ? ? Psychomotor Retardation ? ? ? ? Emotional Trauma Perpetrator ? ? ? ? Self - Mutilation ? ? ? ? Emotional Trauma Victim ? ? ? ? Sexual Dysfunction ? ? ? ? Emotionality ? ? ? ? Sexual Trauma Perpetrator ? ? ? ? Fatigue/Low Energy ? ? ? ? Sexual Trauma Victim ? ? ? ? Generalized Anxiety ? ? ? ? Significant Weight Gain/Loss ? ? ? ? Grief ? ? ? ? Sleep Disturbance ? ? ? ? Guilt ? ? ? ? Social Isolation ? ? ? ? Hallucinations ? ? ? ? Somatic Complaints ? ? ? ? Hopelessness ? ? ? ? Substance Abuse ? ? ? ? Hyperactivity ? ? ? ? Worthlessness ? ? ? ? Irritability ? ? ? ? Other ? ? ? ? Name _________________ Patient ID _______ __ Patient SSN ___________ Date _________ Date of Birth _ __ _______ Page 2 Emotional/Psychiatric History ? No ? Yes Prior out patient psychotherapy? If yes, on occasions. Longest treatment by for sessions from / to / Provider Name Month/Year Month/Year Prior provider name City State Diagnosis Intervention/Modality Beneficial? ____________________ ___________ ____ ________________ ___________________ __________ ____________________ ___________ ____ ________________ ___________________ __________ ? No ? Yes Has any family member had outpatient psychotherapy? If yes, who/why (list all): _____________________________________________________________________________________ ___________ ________________ _________________________________________________________________________________________________________ _______ ? No ? Yes Prior in patient treatment for a psychiatric, emotional, or substance use disorder? If yes, on occasions. Longest treatment at ____________ from / to / Name of facility Month/Year Month/Year Inpatient facility name City State Diagnosis Intervention/Modality Beneficial? ____________________ ___________ ____ ________________ ___________________ ___________ ____________________ ___________ ____ ________________ ___________________ ___________ ? No ? Yes Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes, who/why (list all): ___________________________________________________________________________________________________________ ___ ______________________________________________________________________________________________________________ ? No ? Yes Prior or current psychotropic medication usage? If yes: Medication Dosage Frequency Start Date End Date Physician ____________________ ___________ ____ _____ ___________ _____________ ___________________ _________ _ ____________________ ___________ ____ _____ ___________ _____________ ___________________ _________ _ ? No ? Yes Has any family member used psychotropic medications? If yes, who/what/why (list all): _____________________________________________________________________________________________________________________ ____________________________________________________ _________________________________________________________________