PSYCHIATRIC EVALUATION

Patient: [Name]
Date of birth: [Date]
Date of evaluation: [Date]
Setting: [Outpatient, inpatient, emergency, or telehealth]
Clinician: [Name, credentials]

IDENTIFYING INFORMATION
Identifying data: [Age, gender, living situation, work or school]
Referral source: [Who referred, and the question they are asking]
Sources of information: [Patient, family or others with consent, records reviewed]
Reliability: [How reliable the history seems, and why]

CHIEF COMPLAINT
In the patient's words: [Reason for the evaluation, quoted]

HISTORY OF PRESENT ILLNESS
Onset and course: [When symptoms began, triggers, and how they have changed]
Current symptoms: [Mood, anxiety, sleep, appetite, energy, concentration, psychosis]
Mania or hypomania screen: [Past or current elevated or irritable mood, less need for sleep, risky behavior]
Functioning: [Work, school, relationships, self-care]
Stressors: [Losses, conflict, health, money, legal]
Treatment so far: [What has been tried for this episode, and the response]

PAST PSYCHIATRIC HISTORY
Previous diagnoses: [Diagnoses, and who made them]
Hospitalizations: [Number, years, reasons, voluntary or involuntary]
Medication trials: [Each medication with dose, duration, response, side effects, and why stopped]
Psychotherapy: [Type, duration, what helped]
Suicide attempts and self-harm: [When, method, intent, medical care needed]
Violence: [Aggression, weapons, legal consequences]

SUBSTANCE USE
Alcohol: [Amount, frequency, last use; AUDIT-C or other screen]
Cannabis: [Form, amount, frequency]
Other substances: [Type, route, frequency, last use]
Tobacco and nicotine: [Type and amount]
Withdrawal and treatment: [Withdrawal seizures or delirium, past treatment, periods of abstinence]

MEDICAL HISTORY
Medical conditions: [Including thyroid, neurological, cardiac, head injury, seizures]
Current medications: [All medications with doses, including over-the-counter and supplements]
Allergies: [Drug and other allergies, with reactions]
Reproductive health: [Pregnancy, postpartum, or contraception, when relevant]

FAMILY PSYCHIATRIC HISTORY
Relatives affected: [Mood, anxiety, psychotic, and substance use disorders, and suicide, with the relationship]
Treatment response in family: [Medications that helped relatives]

SOCIAL HISTORY
Upbringing and development: [Childhood, education, trauma]
Current situation: [Relationships, children, work or school, money, housing]
Supports: [Family, friends, community, faith]
Legal: [Current or past legal issues]

MENTAL STATUS EXAM
Appearance: [Grooming, dress, apparent age]
Behavior: [Eye contact, engagement, psychomotor activity, abnormal movements]
Speech: [Rate, volume, tone, fluency]
Mood: [In the patient's words]
Affect: [Range, intensity, stability, congruence with mood]
Thought process: [Linear, circumstantial, tangential, or disorganized]
Thought content: [Preoccupations, obsessions, delusions, suicidal or homicidal ideation]
Perception: [Hallucinations, and whether responding to internal stimuli]
Cognition: [Alertness, orientation, attention, memory; screening score if done]
Insight: [Understanding of the illness and the need for treatment]
Judgment: [As shown by recent decisions]

RISK ASSESSMENT
Suicidal ideation: [Passive or active, frequency, intent, plan, preparation]
Screening tool: [Such as the C-SSRS, with result]
Risk factors: [Past attempts, recent loss, substance use, hopelessness, impulsivity]
Protective factors: [Reasons for living, supports, engagement in care, future plans]
Access to lethal means: [Firearms, stockpiled medications, other means, and what was agreed]
Violence risk: [Thoughts of harming others, target, history, access to weapons]
Risk formulation: [Acute and chronic risk, low, moderate, or high, with your reasoning]
Safety plan: [Warning signs, coping steps, contacts, means safety, emergency steps]

DIAGNOSTIC IMPRESSION
Formulation: [Biological, psychological, and social factors that explain the presentation]
Diagnoses: [Primary and other diagnoses, with specifiers]
Differential: [Other diagnoses considered, including medical and substance causes]

PLAN
Medications: [Start, change, or continue, with dose, rationale, and the consent discussion]
Psychotherapy: [Type, frequency, referral]
Labs and monitoring: [Baseline labs, ECG, rating scales to repeat]
Safety: [Safety plan, means safety, level of care]
Coordination: [Primary care, therapist, family involvement with consent]
Follow-up: [When, with whom, and when to seek help sooner]

Signed: [Clinician name, credentials, date and time]