"Initial Psychiatric Assessment Evaluation Form"

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Initial psychiatric assessment: A practical guide to the clinical interview
1. ID
Name: ________________________________________________
Marital status:__________________________________________
Sex: __________________________________________________
Occupation: ___________________________________________
DOB: ____________________________ Age: ________________
Financial situation: ______________________________________
2. HPI ONSET, DURATION, COURSE
(Why present now/precipitants/stressors? When it started? How long it lasts/frequency? What is it like? Impact on life)
For episodic illnesses describe first episode:
1. Onset:
2. Precipitants:
3. Duration:
4. Rx response:
DEPRESSION (“Sigecaps”)
MANIA (“Giddiness”)
PSYCHOSIS
PANIC ATTACKS
Low mood for >2 weeks
Grandiose
Hallucinations/illusions
Trembling
Sleep
Increased activity
Delusions
Palpitations
Interest
goal-directed/high risk
Self-reference:
Nausea/chills
Guilt/worthlessness
Decreased judgment
people watching you
Choking/chest pain
Energy
Distractible
talking about you
Sweating
Concentration
Irritability
messages from media
Fear:
Appetite/weight ∆
Need less sleep
Thought blocking/insertion
dying/going crazy
Psychomotor slowing
Elevated mood
Disorganization:
Anticipatory anxiety
Suicide:
Speedy talking
speech/behavior
Avoidance
Hopelessness/Plan/Access
Speedy thoughts
Agoraphobia
GENERALIZED ANXIETY
OBSESSIVE-COMPULSIVE DISORDER
PTSD
Excess worry
Intrusive/persistent thoughts
Experienced/witness event
Restless/edgy
Recognized as excessive/irrational
Persistent re-experiencing
Easily fatigued
Repetitive behaviors:
Dreams/flashbacks
Muscle tension
Washing/cleaning
Avoidance behavior
sleep
Counting/checking
Hyper-arousal:
concentration
Organizing/praying
vigilance/
startle
SOCIAL PHOBIA
BORDERLINE PESONALITY
ANTISOCIAL PERSONALITY
Performance situations:
Fear abandonment/rejection
Forensic history:
Fear of embarrassment
Unstable relationships
arrests/imprisonment
Fear of humiliation
Chronic emptiness
Aggressiveness/violence
Criticism
self esteem
Lack of empathy/remorse
Intense anger/outbursts
Lack of concern for safety:
SPECIFIC PHOBIAS
Self-damaging behavior
self or others
Heights/crowds/animals
Labile mood and impulsivity
Childhood conduct disorder
BODY DYSMORPHIC DISORDER
EATING DISORDERS
Excess concern with appearance
Binging/purging/restriction/amenorrhea
or certain part of body
Perception of body image or weight
Avoidance behavior
Initial psychiatric assessment: A practical guide to the clinical interview
1. ID
Name: ________________________________________________
Marital status:__________________________________________
Sex: __________________________________________________
Occupation: ___________________________________________
DOB: ____________________________ Age: ________________
Financial situation: ______________________________________
2. HPI ONSET, DURATION, COURSE
(Why present now/precipitants/stressors? When it started? How long it lasts/frequency? What is it like? Impact on life)
For episodic illnesses describe first episode:
1. Onset:
2. Precipitants:
3. Duration:
4. Rx response:
DEPRESSION (“Sigecaps”)
MANIA (“Giddiness”)
PSYCHOSIS
PANIC ATTACKS
Low mood for >2 weeks
Grandiose
Hallucinations/illusions
Trembling
Sleep
Increased activity
Delusions
Palpitations
Interest
goal-directed/high risk
Self-reference:
Nausea/chills
Guilt/worthlessness
Decreased judgment
people watching you
Choking/chest pain
Energy
Distractible
talking about you
Sweating
Concentration
Irritability
messages from media
Fear:
Appetite/weight ∆
Need less sleep
Thought blocking/insertion
dying/going crazy
Psychomotor slowing
Elevated mood
Disorganization:
Anticipatory anxiety
Suicide:
Speedy talking
speech/behavior
Avoidance
Hopelessness/Plan/Access
Speedy thoughts
Agoraphobia
GENERALIZED ANXIETY
OBSESSIVE-COMPULSIVE DISORDER
PTSD
Excess worry
Intrusive/persistent thoughts
Experienced/witness event
Restless/edgy
Recognized as excessive/irrational
Persistent re-experiencing
Easily fatigued
Repetitive behaviors:
Dreams/flashbacks
Muscle tension
Washing/cleaning
Avoidance behavior
sleep
Counting/checking
Hyper-arousal:
concentration
Organizing/praying
vigilance/
startle
SOCIAL PHOBIA
BORDERLINE PESONALITY
ANTISOCIAL PERSONALITY
Performance situations:
Fear abandonment/rejection
Forensic history:
Fear of embarrassment
Unstable relationships
arrests/imprisonment
Fear of humiliation
Chronic emptiness
Aggressiveness/violence
Criticism
self esteem
Lack of empathy/remorse
Intense anger/outbursts
Lack of concern for safety:
SPECIFIC PHOBIAS
Self-damaging behavior
self or others
Heights/crowds/animals
Labile mood and impulsivity
Childhood conduct disorder
BODY DYSMORPHIC DISORDER
EATING DISORDERS
Excess concern with appearance
Binging/purging/restriction/amenorrhea
or certain part of body
Perception of body image or weight
Avoidance behavior
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
6. SYSTEMS REVIEW
Previous illnesses & treatment:
CNS:
H & N:
Surgeries/hospitalizations:
CVS:
Head injury (+/- LOC) and workup/imaging:
RESP:
Medications:
GI:
GU:
Alcohol use:
MSK:
Substance use: (caffeine, nicotine, over-counter/illicit med/drugs)
DERM:
7. PERSONAL HX
Place of birth:
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)
As an adult: (work, finances, education, relationships, family, goals for future, trends in functioning)
8. MSE
9. FOLSTEIN MMSE
Appearance:
Orientation:
/10
Time:
year
Behavior:
season
month
Speech:
date
day
Emotion: Affect and mood
Place: floor
building
Perception:
city
province
Thought process:
country
Thought content:
Immediate recall:
/3
Attention:
/5
Concentration:
Delay recall:
/3
Naming:
/2
Memory:
Repetition:
/1
3-stage command:
/3
Insight:
Reading:
/1
Copying:
/1
Judgment:
Writing:
/1
Suicide:
Total:
/30
10. IMPRESSION/FORMULATION BIOPSYCHOSOCIAL
11. MULTIAXIAL DIAGNOSIS
Axis I: Psychiatric disorder:
Axis II: Personality:
Axis III: Medical conditions:
Axis IV: Social factors:
12. PLAN
Investigations:
Treatment:
Biological:
Psychological:
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