Presenting Problem

Chief complaint:

Onset / Duration:

Course (improving / stable / worsening):

Severity (mild / moderate / severe):

Triggers / Precipitating factors:

Alleviating factors:

Current Stressors

Financial

Relational / Family conflict

Occupational / School

Legal

Housing instability

Health concerns

Grief / Loss

Client goals for treatment:

Psychiatric History

Prior diagnoses (check all that apply):

Major Depressive Disorder

Generalized Anxiety Disorder

PTSD / Trauma-related disorder

Bipolar Disorder

Substance Use Disorder

ADHD

Eating Disorder

Personality Disorder

No prior diagnoses

Prior therapy (type, duration, outcome):

Prior psychiatric hospitalizations:

Prior medication trials:

History of self-harm:

Prior suicide attempts:

Family Psychiatric History

Check all present in family:

Depression

Anxiety

Bipolar Disorder

Schizophrenia / Psychosis

Substance abuse

Suicide (completed or attempts)

ADHD

No known family psychiatric history

Details (relationship, notes):

Medical History

Relevant conditions (check all that apply):

Chronic pain

TBI / Head injury

Seizure disorder

Thyroid disorder

Autoimmune

Cardiovascular

Diabetes

Sleep disorder

Pregnancy / Postpartum

No significant medical history

Additional medical notes:

Current Medications

Medications Add Medication

New Medication

Drug Name

e.g. Amoxicillin

Drug Code

RxNorm code...

Strength

e.g. 500 mg

Route

Select...

Frequency

Select...

Start Date

YYYY-MM-DD

Stop Date

YYYY-MM-DD

Notes

Notes / instructions...

Substance Use History

1. How often do you have a drink containing alcohol?

Never≤Monthly2-4×/month2-3×/week≥4×/week

2. How many standard drinks do you have on a typical drinking day?

1-23-45-67-910+

3. How often do you have 6 or more drinks on one occasion?

NeverMonthlyWeeklyDaily

1. Have you used drugs other than those required for medical reasons?

Yes No

2. Do you abuse more than one drug at a time?

Yes No

3. Are you always able to stop using drugs when you want to?

Yes No

4. Have you had blackouts or flashbacks as a result of drug use?

Yes No

5. Do you ever feel bad or guilty about your drug use?

Yes No

6. Does your spouse (or parents) ever complain about your involvement with drugs?

Yes No

7. Have you neglected your family because of drug use?

Yes No

8. Have you engaged in illegal activities to obtain drugs?

Yes No

9. Have you had withdrawal symptoms when you stopped taking drugs?

Yes No

10. Have you had medical problems as a result of your drug use?

Yes No

Substance use notes:

Trauma History

Trauma Events

+ Add Event

Approximate Timing

e.g. childhood, age 14, 2018...

Narrative

Adverse Childhood Experiences

1. Emotional abuse by parent or adult in household

Yes No

2. Physical abuse by parent or adult in household

Yes No

3. Sexual abuse

Yes No

4. Felt no one in family loved or supported you

Yes No

5. Lacked food, clothing, or protection due to neglect

Yes No

6. Parents separated or divorced

Yes No

7. Mother or stepmother treated violently

Yes No

8. Lived with someone with substance use problem

Yes No

9. Lived with someone with mental illness or attempted suicide

Yes No

10. Household member went to prison

Yes No

Social History

Living situation:

Support system:

Relationship status:

Children:

Employment / Education:

Legal involvement:

Military service:

Social Determinants of Health

Determinants Spokes

Sleep and Rest

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Notes

Nutrition

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Notes

Movement

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Notes

Stress Load

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Notes

Relationships

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Notes

Environment

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Notes

Purpose

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Notes

Community

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Notes

Resilience

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Notes

Access and Resources

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Notes

WHO-5 Well-Being Index

administered Past two weeks · cutoff 13/25

1 Cheerful and in Good Spirits