Chief complain Patient Goals For Evaluation Presenting problem/primary symptoms
PsychiatristNeurologistCardiologistAlternative/Holistic/NaturopathicTherapyPsychiatric Inpatient HospitalizationOutpatient Treatment ProgramOther
Describe your parents' attitudes toward their pregnancy with you: Were there any pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking, alcohol/drug use, etc) that you know of? Were there any birth problems, trauma, forceps or complications that you know of? Allergies/Drug intolerances? Head/Brain Trauma Seizures or seizure like activityPeriods of spaciness or confusionConcussionWhiplashLoss of consciousnessHead traumaStitches on face or head
Current diet Restricted diet Experience with Gluten free diet Experience with Casein free diet Appetite Fruits Vegetables Breakfast Caffeine Food allergies/Sensitivities Current bowel function Current exercise regimen Seeking treatment for weight related issues Times per day you eat Typical eating schedule Eight glasses of water per day Over or underweight Ideal weight BMI How long struggled with weight issues Weight loss measures tried
Do you or have you ever experienced withdrawal symptoms from alcohol or drugs? Has anyone told you they thought you had a problem with drugs or alcohol? Have you ever felt guilty about your drug or alcohol use? Have you ever felt annoyed when someone talked to you about your drug or alcohol use? Have you ever used drugs or alcohol first thing in the morning? Problems falling asleep yesno Problems staying asleep yesno Problems waking up yesno Average hours slept per night Sleep related issues yesno
Biological mother's history:
Biological father's history:
Significant Life Events: Significant Perceived Successes: Significant Perceived Failures Relationship with Mother: Relationship with Father: Sexual history: History of abuse: Description of self: Description of strengths:
Spiritual background Personal impact of spiritual background: Practices that produce "Spiritual Fruit": Belief in a higher power? Explain: Purpose or mission: Unusual spiritual experience:
Appearance Attitude Behavior Eye Contact Speech Orientation Mood (in patient's own words) Affect Thought process Worries/Obsessions Delusions? Suicidal ideation? Homicidal ideation? Hallucinations Illusions Deja vu Serial sevens Memory Judgment Abstraction Relatedness
Please review the symptoms below and place a check in the appropriate box if you or any of your family members have had the problems listed:
Anxiety SelfMotherFatherBrotherSisterChildrenOther Relatives Panic attacks SelfMotherFatherBrotherSisterChildrenOther Relatives Phobias SelfMotherFatherBrotherSisterChildrenOther Relatives Depression SelfMotherFatherBrotherSisterChildrenOther Relatives Seasonal mood changes (SAD) SelfMotherFatherBrotherSisterChildrenOther Relatives Elevated mood SelfMotherFatherBrotherSisterChildrenOther Relatives Bipolar SelfMotherFatherBrotherSisterChildrenOther Relatives Mania SelfMotherFatherBrotherSisterChildrenOther Relatives Irritability SelfMotherFatherBrotherSisterChildrenOther Relatives Hot temper SelfMotherFatherBrotherSisterChildrenOther Relatives Self-mutilation SelfMotherFatherBrotherSisterChildrenOther Relatives Suicide attempts SelfMotherFatherBrotherSisterChildrenOther Relatives Psychiatric SelfMotherFatherBrotherSisterChildrenOther Relatives Social SelfMotherFatherBrotherSisterChildrenOther Relatives Hallucinations SelfMotherFatherBrotherSisterChildrenOther Relatives Schizophrenia SelfMotherFatherBrotherSisterChildrenOther Relatives Psychosis SelfMotherFatherBrotherSisterChildrenOther Relatives Paranoia SelfMotherFatherBrotherSisterChildrenOther Relatives Delusions SelfMotherFatherBrotherSisterChildrenOther Relatives Dissociative states SelfMotherFatherBrotherSisterChildrenOther Relatives Grief SelfMotherFatherBrotherSisterChildrenOther Relatives ADHD SelfMotherFatherBrotherSisterChildrenOther Relatives Concentration difficulties SelfMotherFatherBrotherSisterChildrenOther Relatives Attention difficulties SelfMotherFatherBrotherSisterChildrenOther Relatives Hyperactivity SelfMotherFatherBrotherSisterChildrenOther Relatives Intolerance of boredom SelfMotherFatherBrotherSisterChildrenOther Relatives Learning/School difficulties SelfMotherFatherBrotherSisterChildrenOther Relatives Juvenile delinquency SelfMotherFatherBrotherSisterChildrenOther Relatives Defiant SelfMotherFatherBrotherSisterChildrenOther Relatives Fire setting SelfMotherFatherBrotherSisterChildrenOther Relatives Bedwetting SelfMotherFatherBrotherSisterChildrenOther Relatives Cruelty to SelfMotherFatherBrotherSisterChildrenOther Relatives Legal SelfMotherFatherBrotherSisterChildrenOther Relatives Anger or rage SelfMotherFatherBrotherSisterChildrenOther Relatives Obsessions or SelfMotherFatherBrotherSisterChildrenOther Relatives Anorexia Nervosa SelfMotherFatherBrotherSisterChildrenOther Relatives Bulimia SelfMotherFatherBrotherSisterChildrenOther Relatives Laxative/Diuretic abuse SelfMotherFatherBrotherSisterChildrenOther Relatives Alcohol SelfMotherFatherBrotherSisterChildrenOther Relatives Drug/Substance abuse SelfMotherFatherBrotherSisterChildrenOther Relatives Head injury SelfMotherFatherBrotherSisterChildrenOther Relatives Concussion SelfMotherFatherBrotherSisterChildrenOther Relatives Tourette's Syndrome SelfMotherFatherBrotherSisterChildrenOther Relatives Amnesia SelfMotherFatherBrotherSisterChildrenOther Relatives Dementia SelfMotherFatherBrotherSisterChildrenOther Relatives Narcolepsy SelfMotherFatherBrotherSisterChildrenOther Relatives Irresistible sleep SelfMotherFatherBrotherSisterChildrenOther Relatives Sleep Apnea SelfMotherFatherBrotherSisterChildrenOther Relatives Heavy snoring during SelfMotherFatherBrotherSisterChildrenOther Relatives Hallucinations going to SelfMotherFatherBrotherSisterChildrenOther Relatives Hallucinations when SelfMotherFatherBrotherSisterChildrenOther Relatives Restless legs during SelfMotherFatherBrotherSisterChildrenOther Relatives Night terrors SelfMotherFatherBrotherSisterChildrenOther Relatives Sleepwalking SelfMotherFatherBrotherSisterChildrenOther Relatives Sexual difficulties SelfMotherFatherBrotherSisterChildrenOther Relatives Sexual abuse victim SelfMotherFatherBrotherSisterChildrenOther Relatives Sexual abuse perpetrator SelfMotherFatherBrotherSisterChildrenOther Relatives Physical abuse victim SelfMotherFatherBrotherSisterChildrenOther Relatives Physical abuse SelfMotherFatherBrotherSisterChildrenOther Relatives Mental SelfMotherFatherBrotherSisterChildrenOther Relatives Autism SelfMotherFatherBrotherSisterChildrenOther Relatives Asperger's Disorder SelfMotherFatherBrotherSisterChildrenOther Relatives Pervasive Developmental D/O SelfMotherFatherBrotherSisterChildrenOther Relatives Sensitivity to SelfMotherFatherBrotherSisterChildrenOther Relatives
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