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PsychiatricEvaluation
Patient Name DOB MRN
©MB and RR 2006-2010 e-medtools.com Revised 2Dec09 Health Care Provider Initials or Signature
Review of SystemsChief complaint/Reason for consult
Start Time Stop Time Date
Review of SystemsYesNoConstitution
Fatigue or Malaise
Fever or chills
Appetite changes
Eyes
Conjunctivitis
Eye painVisionchanges
ENT/mouth
Sore throatEpistaxisRhinorrhea
Respiratory
DyspneaCoughWheeze
Cardiovascular
Chest pain Ankle edemaPalpitations
Gastrointestinal
Nausea or vomitingWeight changes Abdominalpain
Genitourinary
HematuriaDysuriaUrethral discharge
Musculoskeletal
Myalgias ArthralgiasJoint swelling
Skin/Breasts
MassesNew skin lesionsRash
Neurologic
HeadachesSeizuresParesthesias
Endocrinologic
Hair lossPolydipsiaTremors
Heme/Lymph
Bleeding gumsUnusual bruisingSwollen lymph nodes
Allergy/Immunology
Nasal congestion
Psychiatric
AgitationHallucinationsDepressed moodInsomniaHypersomnia Altered concentrationFeels worthlessGrandiose ideasCompulsionsBelieves they havespecial powersNew / increasedsubstance abuse
History of Present Illness
Patient is Nonverbal. History obtained from
Family
Medical records
Suicidal ideation
Yes
No Plan formed
Yes
NoPatient has the means to carry out the plan
Yes
No
Homicidal ideation
Yes
NoPlan formed
Yes
No Patient has the means to carry out the plan
Yes
No
Allergies and Medications
Medications reviewed
Medications reconciled with Nursing Home or Hospital data
Allergy List reviewed
No drug allergies
No food allergies
History of life threatening allergic response to
Past Medical History, Social History and Family History
Yes
No Arrhythmias
Yes
No HIV/AIDS
Yes
No Thyroid disease
Yes
No Asthma
Yes
No Kidney disease
Yes
No Tuberculosis
Yes
No Coronary Artery Disease
Yes
NoLiver disease
Yes
NoMalignancy
Yes
No COPD
Yes
No Porphyria
Yes
No Diabetes
Yes
No Seizures
Yes
NoNeuroleptic Malignant Syndrome
Yes
No Heart Failure
Yes
No Syphilis
Yes
NoMalignant Hyperthermia
Past Surgical History
Past Psychiatric History
Yes
No Anxiety
Yes
No
Hospitalizations for psychiatric illnesses
Yes
No Bipolar disorder
Yes
No Depression
Yes
No
History of Electroconvulsive Shock Therapy
Yes
No Mania
Yes
No Psychosis
Yes
No
Prior Suicide attempts
Yes
No Schizophrenia
Yes
No Personality disorder
Yes
No Other
Social History / Risk factors
Denies
Yes
Ever smoker
___ # Packs X ____ # Yrs
Denies
Yes
Alcohol use
___ Drinks per
day
week
Denies
Yes
Chews tobacco
Denies
Yes
Felt the need to cut down on drinking?
Denies
Yes
Quit tobacco use
Quit date _________
Denies
Yes
Annoyed by others criticizing drinking?
Denies
Yes
Guilt associated with drinking?
Denies
Yes
Feels safe at home or work
Denies
Yes
Eye opener needed?
Denies
Yes
Tattoos
Denies
Yes
High risk sexual behavior
Denies
Yes
Recreational drug use
Inhalational
Injectable
Ingestible
Denies
Yes
Prescription Drug dependence
Narcotics
Benzodiazepines
Family Medical History
Asthma
CHF
COPD
Coronary Artery Dis
Pancreatitis
Peripheral Artery Disease
Renal Dysfunction
Thalassemia
Thrombotic disorder
Thyroid Disease
Malignancy
Other
Anxiety disorder
Bipolar disorder
Depression
Schizophrenia
Suicide or Suicide attempts
PsychiatricEvaluation
Patient Name DOB MRN
©MB and RR 2006-2010 e-medtools.com Revised 2Dec09 Health Care Provider Initials or Signature
Exam
To qualify as a comprehensive exam: Document every all of the bullets in Constitutional (including at least 3 vital signs) and the Psychiatric sections AND at least one bullet in the Musculoskeletal section.
VitalsHeight
_____
in
cm
Weight
_____
lb
kg
Temperature
_____
Pulse
Rate
_____
Rhythm
Regular
Irregular
Blood Pressure
________
Sitting
Standing
Lying
________
Sitting
Standing
Lying
Respiratory Rate
_____
Labs
\____/ ____ / ____ / ____ // \ \ \ \
Radiology
Additional Exam Findings
Constitutional
(
3 vitals)
Body habitus
and
Grooming
required of General Multisystem but not Organ System Exam
x
General Appearance
Well nourished
Cachectic
Obese
Grooming
Appropriate
Unkempt
Deformities
None noted Present as follows
Musculoskeletal
x
Strength & Muscle tone
Within normal limits
Increased
Decreased
Flaccid
Cogwheel
Atrophy
x
Gait & Station
Within normal limits
Ataxia
Wide based gait
ShufflePatient leans
Rt
Lt
Forward
Backward
Psychiatric
x
Speech
(Describe Rate, Volume, Articulation, Coherence, Spontaneityand include abnormalities)
x
Thought processes
(Describe Rate, Content, Abstract reasoning and Computation)
x
Associations
Intact
Loose
Tangential
Circumstantial
x
Thoughts
Within normal limits
Illogical
Hallucinations
Obsessions
Preoccupation with violence
Homicidalideation
Suicidal ideation
x
Judgment and Insight Mental Status
x
Orientation
Oriented to Person, Time, and Place
NOT
oriented to
Person
Time
Place
x
Recent &Remote Memory
x
Attention Span &Concentration
x
Language
x
Fund of Knowledge
x
Mood &Affect
Within normal limits
Agitated
Anxious
Depressed
Hypomanic
Labile
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