Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________
Appetite: ________________________
Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
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Outpatient psychiatric treatment:
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Detox/Inpatient substance treatment:
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History of suicide attempts and/or self injurious behaviors:
____________________________________
Past Medical History
· Major/Chronic Illnesses____________________________________________________
· Trauma/Injury ___________________________________________________________
· Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
_________________________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________ ________________________________
_________________________________________ ________________________________
Substance use
: (alcohol, marijuana, cocaine, caffeine, cigarettes)
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Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________
Marital Status:________
Education:____________________________
Employment Status: ______
Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____
Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone
: _____________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia
Exposures:
Immunization HX:
Review of Systems (at least 3 areas per system):
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (
percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
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Psychotherapy Note |
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Therapeutic Technique Used: |
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Session Focus and Theme: |
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Intervention Strategies Implemented: |
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Evidence of Patient Response: |
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan:
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis #2
Diagnostic Testing/Screening Tool:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Patient/Family Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Rev. 2272022 LM
