Psychiatric Evaluation

Patient Name:
MR:
Presenting Problem:
Depression
Anxiety
Substance Use
Mood Disorder
Head Trauma
Other
Comments:
History of Violence:
Suicide Potential:
Significant sense of loss (loved one, pet, employment, etc)
Significant sense of hardship (financial, legal, etc)
Significant sense of separation
Substance abuse or dependence
Significant unstable physical environment (below poverty level, lack of shelter, difficult foster placement, etc)
Family history of suicide attempt
Previous patient suicide attempt
Significant depression
Risk for Suicide: Yes No
Suicidal Ideation: Yes No
Suicidal Means/Plan: Yes No If yes, implement suicide precautions, notify physician, refer to hospital
Suicidal Intent: Yes No If yes, implement suicide precautions, notify physician, refer to hospital
Risk for Homicide: Yes No
Homicidal Ideation: Yes No
Homicidal Intent: Yes No
Homicidal Means/Plan: Yes No If yes, implement homicide precautions, notify authorities, etc.
Past Psychiatric Treatment:
Age of Onset:
Number of Hospitalizations:

Social History

Place of Birth:
Raised By:
Came to(State)
When/why:
Ethnic/Cultural Background:
Family/Siblings Structure:
Family History of Mental Illness: Yes No
If yes, relation:
Family History of Drug and/or Alcohol Abuse: Yes No
If yes, explain
Current Relationship with Family:
Other Social Relationships:
Sexual Orientation
Currently Sexually Active: Yes No
Ever Married: Yes No
Number of Marriages:
Children: Yes No
Number of Children:
Spiritual Orientation:
Baptist
Buddhist
Catholic
Christian
Eastern Orthodox
Hindu
Jehovah's Witness
Jewish
Muslim
None
Other
Religion of Family:
Baptist
Buddhist
Catholic
Christian
Eastern Orthodox
Hindu
Jehovah's Witness
Jewish
Muslim
None
Other
Education Level:
High School
Associates
Bachelors
Higher Education
Other
Special Education History: Yes No
Living Situation:
Homeless
House/Apartment
Other
Source of Income:
Employed
Unemployed
Disability
Social Security
Other
Last worked:
Employment History:
Military Service:
Physical Abuse : Yes No
If yes, by who
Sexual Abuse as Perpetrator: Yes No
Sexual Abuse as a Victim: Yes No
If yes, by who:
Have charges been brought? Yes No
Dealt with in counseling? Yes No
Legal
Criminal History: Jail Prison Prison
Parole/Probation Officer:
Medical
Surgeries Yes No
Hospitalizations Yes No
History of Seizures Yes No
History of Head Trauma Yes No
Comments
Substance First Used Progression Last Used
Alcohol
Cannabis
Cocaine
Methamphetamine
Hallucinogens
Opioids
Benzodiazepines
Nicotine
Other
Previous Treatments: Detoxification Residential Other
Where

Mental Status Examination

Appearance:
Appropriate dress
Inappropriate
Disheveled
Well-groomed
Unkempt
Malodorous
Other
Hygiene: Good Fair Poor
Build:
Average
Underweight
Slender
Petite
Obese
Motor Activity:
Agitated
Hypoactive
Retardation
Abnormal movement
Other
Sensorium:
Alert
Oriented
Disoriented
Drowsy
Sedated
Confused
Other
Attention: Good Fair Limited Poor
Speech:
Normal rate
Loud
Rapid
Pressured
Verbose
Soft
Slow
Monotone
Spontaneous
Impediment
Slurred
Other
Attitude:
Cooperative
Uncooperative
Hostile
friendly
Trustful
Evasive
Suspicious
Seductive
Argumentative
Other
Mood:
Euthymic
Depressed
Sad
Anxious
Euphoric
Happy
Irritable
Other
Affect:
Appropriate
Expansive
Euphoric
Anxious
Tearful
Labile
Apathetic
Blunted
Constricted
Flat
Other
Thought Process:
Linear
Goal-directed
Circumstantial
Tangential
Blocking
Incoherent
Loose
Impoverished
Racing
Flight of ideas
Other
Thought Content:
Delusions: No Yes
Hallucinogens: No YES (Auditory/Visual)
Preoccupations/Obsessions/Compulsions/Phobias: No YES
Cognition/Memory: Intact Impaired Unable to asses
Impression of Intelligence: Average Below average Above average Intellectual disability
Insight: Good Fair Limited Poor
Judgment: Good Fair Limited Poor
Interpersonal Style:
Open
Cooperative
Compliant
Withdrawn
Relaxed
Shy
Hostile
Engaging
Defensive
Resistant
Annoyed
Irritable
Guarded
Cautious
Other

DIAGNOSIS:

Substance Use Disorder:
Alcohol
Cannabis
Cocaine
Meth
Opioid
Defensive
Sedative
Hallucinogen
Nicotine
Other
Anxiety Disorder:
Substance-induced anxiety disorder
Generalized anxiety disorder
Social anxiety disorder
Panic disorder
Other
Depressive Disorder:
Substance-induced depressive disorder
Major depressive disorder
Depressive disorder NOS
Other
Other Disorder:
Post-traumatic Stress Disorder: Bipolar Disorder Cognitive Disorder Other

PLAN:

Suicide/Homicide Risk: Yes No Other
Recommend 30 minute watch Recommend for therapist to do intervention Transfer patient to emergency room Recommend buddy watch Inform affected party
Recommendation:
Name of Physician:
Date:
Signature: