Psychiatric Intake Assessment – Form Patient Name *Email Address *Date of Birth *Time in *Accompanied by *Emergency name and number *Relationship to the patient *Patient Alternate phone number *None known *ExplainName *Dosage/Frequency *When startedCHIEF COMPLAINT/DURATION: (per triage sheet)B/P *P *Ht *Wt *Primary care physician *Recent labsEEGCT/MRIConstitutional (eg: weight loss, fever)YesNoCardiovascular/HypertensionYesNoGI/LiverYesNoNeurological (eg: Seizure, CVA)YesNoMusculoskeletalYesNoHematologic/LymphaticYesNoCancerYesNoRespiratory (eg: COPD, asthma)YesNoHEENTYesNoGUYesNoSkinYesNoEndocrine (eg: diabetes, thyroid)YesNoAllergic/ImmunologicYesNoHead/traumaYesNoHospitalizationsYesNoSurgeriesYesNoSignificant Dx’sYesNoCardiovascular/HypertensionYesNoGI/LiverYesNoNeurological (eg: seizures, CVA, Parkinsons, Huntingtons)YesNoCancerYesNoRespiratory (eg: COPD, asthma)YesNoGUYesNoEndocrineYesNoOtherYesNoAlcohol/Substance abuseYesNoPsychiatric historyYesNoBorn where? *Raised where? *Birth order *BrothersSistersParents divorced?YesNoSpecificsMembers in household * *Marital status and/or current relationshipSMDWHow long?When?Comments:ChildrenYesNoHow many sons?Daughters?EducationProblemsJob descriptionHow long?Problems?Military historyPAST PSYCHIATRIC HX:Substance “Use” history: (type, duration, severity, treatment Hx; include caffeine & tobacco)History of emotional, physical or sexual abuse:Current Stressors: legal, financial, interpersonal:SleepYesNoCurrent Stressors: legal, financial, interpersonal:AppetiteYesNoEnergyYesNoInterest/MotivationYesNoConcentrationYesNoMemoryYesNoHopelessnessYesNoManic SymptomsYesNo(panic, phobias, autonomic symptoms, generalized anxiety)YesNoOCD SymptomsYesNo(Auditory/Visual Hallucinations, paranoia, delusional ideas)YesNoCurrentYesNoPastYesNoHomicidal or Assaultive Behaviors:YesNoEating Disorder:YesNoCognitive Deficits: (orientation, MR, intellectual decline, wandering, language)YesNoADD Symptoms:YesNoComments:YesNoIntake RN SignatureDate Submit
