PSYCH&& & Date:&

ID# • Have&you&ever&seen&things&and&wondered&if&they&are&really&there?&
• Name/Age& • When&you&are&alone&do&you&hear&voices&inside&your&head?&
• Work/School& • Things&touching&you,&smells?&
• Living&Situation& • Special&messages&from&TV/&radio&etc.?&
CC# PMH/#PPH#
# • Experienced&something&like&this&before?&
• What&can&I&do&for&you&today?& • Treated?&&
• Why&did&you&come&to&the&hospital?&& • Counseling/&psychiatrist?&
• Voluntary/certified?& • Doing&better?&In&what&way?&
• When&admitted?&Difficulties&at&that&time?& &
& Medical&problems?&&
HPI# Heart&Disease,&Cancer,&Lung/Kidney&Disease,&Diabetes,&Auto&
# Accidents,&Fractures,&Head&Injuries&(unconscious)…&
• How&long?&Had&before?&(treated?)& • Hospital&admissions&for&other&reasons?&
• Stressors/&triggers?& • Head&injuries?&Seizures?&Hypothyroid?&
• How&long&since&you&felt&well?& • Surgeries?&
• How&are&you&coping?& Family#Hx#
• Interfering&with&life?&Activities?&Relationships?& • Similar&problems/&situation?&
• Anything&you&feel&could&have&caused&this?*& • Had&a&mental&illness?&Treated?&
• Anyone&in&a&similar&situation?& • Depressions,&emotional&problems?&
• Why&seeking&treatment&at&this&point&in&your&life?& • Substance&abuse,&Alcohol?&
• Some&of&the&first&symptoms&you&experienced?& &
& Meds##
• Goals/hopes&for&treatment?& • Prescription,&OTC&&
• Plans&for&leaving&hospital/&returning&home?& • From&where?&buy&at&a&drug&store?&
& • Side&effects&
MOOD&& • Supplements/Herbs?&
Depression#(Almost&whole&day,&>2wks,&impairment&of&function)&# Alcohol& Cut&down& Substance#Abuse#
Sleep& • Are&you&depressed?& Smoking& Annoyed& Hazardous&
Drugs& Guilt& Evasive&(work&,&
Interest& • Have&you&felt&down&or&hopeless?&&
Guilt& Caffeine& Eye&opener& responsibilities,&…)&
• Have&you&had&little&interest&in&dayPtoPday& Food&–&eating&out&of&control& Legal&problems&
Energy& activities?& Abuse&
Concentration& Trouble&with&the&Law& Psycho&social&&
• Difficulty&starting&new&projects?& dependence& &
Appetite/Weight&
Psychomotor&
• How&much&walking?&Exercise?& &
Suicide& • How&has&your&appetite&been&lately?& Past#Personal#Hx#
• Birth&order,&problems&with&pregnancy/delivery,&milestones&
• Ever&had&thoughts&regarding&suicide?&
• Relationships&with&family&growing&up?&
(Plans,&means,&attempts)& • School,&friendships,&health,&major&life&events&(death,&illness,&divorce)&
• Known&anyone&who&has&attempted/&completed&suicide?& • Employment,&personal&relationships,&kids,&religion&
• Who&are&your&main&supports?& • Traumatic&experiences&
& • Abuse&(were&you&able&to&tell&anyone?)&
Mania#(>1wk,&hypomania≤4days,&less&impairment)& • Legal&issues&
• Ever&been&a&time&when&you&felt&you&were&moving& &
Self&Esteem& &

Sleep& to&fast&or&people&noticed&change&in&your&behavior,& I&DD&of&DSM&IV&clinical&disorders&&

Talking& anyone&ever&told&you&they&think&you&are…?& II&personality&disorder&(APeccentric,&BP&dramatic,&CP&anxious)&
Pleasurable& o Talking&fast,&Distracted,&Taking&Risks,&not& III&medical&conditions&related&to&mental&disorder&
activities& sleeping&enough….& IV&psychosocial&and&enviro&issues&–&job,&house,&$,&education,&
Activity/Goals& • Doing&things&you&regretted?& supports,&healthcare&
Idea&racing& &
Distracted& V&global&assessment&of&functioning&(0P100)&
# AP paranoid,&schizoid,&schizotypal&
Anxiety## BP antisocial,&borderline,&histrionic,&narcissistic&
1&restless,&on&edge& • Anxious&or&on&edge?& CP avoidant,&dependent,&OC&personality&disorder&
2&fatigues&easily& • Sudden&onset&of&panic?&What&happened?& &
3#&concentration,& Worry&about&more?& TXP&BIOPPSYCHOPSOCIAL&& &
&
blank&mind& • Anything&in&particular&that&you&are&fearful&of?& &

4#irritable&
CognitivePbehavioral&therapy&& &

• Do&you&worry&excessively&& &
5&muscle&tension&
6&sleep&
• Thoughts&or&ideas&you&cant&get&rid&of?& MENTAL#STATUS&&*don’t&list&negatives&
disturbance& • Check,&count,&handwash&/&how&much&time&out& Appearance&
of&the&day& BehaviorP&motor,&activity&level,&tremors&
# Speech&–&coherent,&speed&
Psychosis& Emotion&–&mood&(them),&affect&(us),&congruence&of&content&and&affect&
• Do&you&ever&feel&your&mind&is&playing&tricks&on&you?& Perception&P&sensory&input,&hallucinations,&illusions&
• Feel&anyone&is&trying&to&hurt&you/&planning&against&you?& Thoughts&–form&(circumferential,&tangential,&flight&of&ideas),&content&
• Think&other&people&can&hear&your/take&away/&put&in&thoughts?& (delusions,&obsessions,&compulsions,&preoccupation,&phobias)&
• Special&powers/&abilities?& Insight&–&understanding&of&mental&illness,&tx&compliance&
PSYCH&& & Date:&
Cognition&–&judgment,&memory,&MMSE,&alertness,&orientation,&
attention&
*suicidal/homicidal&ideations&