Name
_________________
Patient ID
_______
__
Patient SSN
___________
Date
_________
Date of Birth _
__
_______
Page
1
Biopsychosocial History
Presenting Problems
Primary
_____________________________________________________________________________________________
______
Secondary
_____________________________________________________________________________________________
______
_____________________________________________________________________________________________
______
Current Symptom Checklist
(Rate intensity of symptoms
currently present)
Mild
= Impacts quality of life, but no significant impairment of day
–
to
–
day functioning
Moderate
= Significant impact on quality of life and/or day
–
to
–
day functioning
Severe
= Profound impact on quality of life and/or day
–
to
–
day functioning
Symptom
Impact
Symptom
Impact
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Aggressive Behaviors
?
?
?
?
Laxative/Diuretic
Abuse
?
?
?
?
Agitation
?
?
?
?
Loose Associations
?
?
?
?
Anorexia
?
?
?
?
Mood Swings
?
?
?
?
Appetite Disturbance
?
?
?
?
Obsessions/Compulsions
?
?
?
?
Bingeing/Purging
?
?
?
?
Oppositional Behavior
?
?
?
?
Circumstantial Symptoms
?
?
?
?
Panic Attacks
?
?
?
?
Concomitant Medical Condition
?
?
?
?
Paranoid Ideation
?
?
?
?
Conduct Problems
?
?
?
?
Phobias
?
?
?
?
Delusions
?
?
?
?
Physical Trauma Perpetrator
?
?
?
?
Depressed Mood
?
?
?
?
Physical Trauma Victim
?
?
?
?
Dissociative States
?
?
?
?
Poor Concentration
?
?
?
?
Elevated Mood
?
?
?
?
Poor Grooming
?
?
?
?
Elimination Disturbance
?
?
?
?
Psychomotor Retardation
?
?
?
?
Emotional Trauma Perpetrator
?
?
?
?
Self
–
Mutilation
?
?
?
?
Emotional Trauma Victim
?
?
?
?
Sexual Dysfunction
?
?
?
?
Emotionality
?
?
?
?
Sexual Trauma
Perpetrator
?
?
?
?
Fatigue/Low Energy
?
?
?
?
Sexual Trauma Victim
?
?
?
?
Generalized Anxiety
?
?
?
?
Significant Weight Gain/Loss
?
?
?
?
Grief
?
?
?
?
Sleep Disturbance
?
?
?
?
Guilt
?
?
?
?
Social Isolation
?
?
?
?
Hallucinations
?
?
?
?
Somatic
Complaints
?
?
?
?
Hopelessness
?
?
?
?
Substance Abuse
?
?
?
?
Hyperactivity
?
?
?
?
Worthlessness
?
?
?
?
Irritability
?
?
?
?
Other
?
?
?
?
Name
_________________
Patient ID
_______
__
Patient SSN
___________
Date
_________
Date of Birth _
__
_______
Page
2
Emotional/Psychiatric History
?
No
?
Yes
Prior
out
patient psychotherapy?
If yes, on
occasions. Longest treatment by
for
sessions from
/
to
/
Provider Name
Month/Year
Month/Year
Prior provider name
City
State
Diagnosis
Intervention/Modality
Beneficial?
____________________
___________
____
________________
___________________
__________
____________________
___________
____
________________
___________________
__________
?
No
?
Yes
Has any family member had outpatient psychotherapy?
If yes, who/why (list all):
_____________________________________________________________________________________
___________
________________
_________________________________________________________________________________________________________
_______
?
No
?
Yes
Prior
in
patient
treatment for a psychiatric, emotional, or substance use disorder?
If yes, on
occasions. Longest treatment
at
____________
from
/
to
/
Name of facility
Month/Year
Month/Year
Inpatient facility name
City
State
Diagnosis
Intervention/Modality
Beneficial?
____________________
___________
____
________________
___________________
___________
____________________
___________
____
________________
___________________
___________
?
No
?
Yes
Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder?
If yes,
who/why (list
all):
___________________________________________________________________________________________________________
___
______________________________________________________________________________________________________________
?
No
?
Yes
Prior or current psychotropic medication usage?
If yes:
Medication
Dosage
Frequency
Start
Date
End
Date
Physician
____________________
___________
____
_____
___________
_____________
___________________
_________
_
____________________
___________
____
_____
___________
_____________
___________________
_________
_
?
No
?
Yes
Has any family member used psychotropic medications?
If yes, who/what/why (list all):
_____________________________________________________________________________________________________________________
____________________________________________________
_________________________________________________________________