ADULT – confidentiality statement Y/N Date: Time: Client#___________ M/F Age: Preferred name:

1. source of info 3. HPI A. Onset / duration/  sx over time B. Precipitants C. Modifying

2. CC D. Baseline function E. Associated sx

4. Mood
5. Stressors money/relationships
How is your life different because of ____________ magic wand / magic pill

6. SX A. Depression PHQ  c menses/time of year  B. GAD-7 Worrier? How long? What do you worry about? Panic attacks?
Center of attention / health or appearance / family member / leaving home / phobias C. Hallucinations? sounds, voices, other people didn’t
D. PTSD Startle easily  E. OCD checking – cleaning behaviors / need things in order / images can’t get out of mind / picking skin – pulling hair
F. Delusion Any special abilities or hear other people’s thoughts  F. Mania  sleep but still energy / start lots of projects / risk behaviors

7. Sleep Bedtime Sleep at up at noc Wakes Naps / Nightmares / Enuresis Feels rested Y/N
8. Energy Norm /  /  Is this a change? Y / N x 9.  memory? Y/N 10.  concentration? Y/N

11. What do you do for fun? Change in interest? Y/ N x

12. Appetite Norm /  /  Does food taste good to you? Y/N Weight loss / gain? Concern re wt?
Breakfast Lunch Dinner Snacks/Soda
13. Gen health Pain Y/N PCP last seen? Pharmacy
14. Medical issues Fx /head inj / sz
ROS
15. Medications Contraception / OTC / vit & herbal
NKDA?
16. LNMP Reg Y/N G P Ab 17. Surgeries

18. Labs/EKG 19. Immunizations Influenza / Pneumonia / Tetanus / Hep A/B

20. Dentist 21. Eye Dr glasses/CL – distance close

22. Where live? House/Apt/trailer Own/rent 23. Born/grew up

24. Work / military A. Current/last job B. Longest job

25. Who in house? Feel – Safe/calm/chaotic

26. Relationships A. prob impact relationships? B. Who in life trust & depend on? C. Friends Keep relationships long? Y/N
Get along with most people Y/N

D. Sex active Y/N

E. Romantic Current ______mo/yr F. Quality G. longest _____ mo/yr M/F/Bi H. Married / Divorced
27. Family Age Occupation Relationship- growing up/now Mental health (drug/ETOH) /med problems
A. Mom
B. Dad
C.
D. Sibs

E. Grandparents

F. Kids

28. EDU Grad/GED/yrs college_______ Major ____________ What was (is) school like? A. Grades B. Friends C. school activities
D. discipline problems, paying attention/sitting still E. accommodations Special ed / IEP/504
 29. Preg/Develop A. Mother’s health during preg? _________________ B. Complications with birth Vag/C-S _________________ C. Drugs Y/N

D. Delay in development E. Med problem or serious injury during childhood

30. Worse thing ever happened to you? Losses death/divorce? 31. Arrests/legal issues

32. Suicide A. When is the last time you thought about suicide or death? B. Fam hx suicide
C. Past attempts What led to this?

D. Self harm? Cut/burn - location How does this help you?

33. Violence Do you have much of a temper? Y/N A. Thoughts or hx or threatening or harming someone? B. Breaking things/punching walls?

34. PSYCH HX
A. Out-pt therapy Y/N Who When

B. Current Meds Taking /7 days Effectiveness/SE C. Past meds

D. Hospitalizations How many in life? Past year? When? Reason? Where?

35. SUD Past tx for ETOH/drugs? 36. Caffeine Coffee/tea Soda Energy

37. Ever smoked / chewed / vape / juuled

Started Amnt pk/d Quit
1. ETOH 2. RX meds 3. Marijuana 4. Spice/K2 5. Opioids/narcotics 6. Meth/speed/amph/salts 7. Cocaine 8. Ecstasy (Molly/MDMA)
9. Heroin 11. Acid 12. Huffing 11. Ketamine

First use Last use Alone/Others Amnt? Increasing? Route Longest sobriety – How? Problems because of use

MSE Assess Memory & Concentration

Orientation  Where are you right now?  Year  Month  Day
3-object recall I’m going to say 3 words and want you to repeat them back. Remember them
 SPOON Something to eat with  BALL Something to play with  RED A color

Concentration  Start at 100 and subtract 7  Start at 50 and subtract 3  If something costs 78 cents and you give the cashier one
& Attention (93, 86, 79, 72, 65, 58, 51, 44) (47, 44, 41, 38, 35, 32, 29, 26) dollar, how much change should you get back? (22 cents)
 Spell WORLD backwards (or watch)  Months of the year backwards starting c Dec

Fund of  6 States border WY (CO/UT/ID/MO/SD/NE)  Presidents (Trump/Obama/Bush)

Knowledge  4 biggest cities in US NY/LA/Chicago/Houston  What was ____ famous for MLK/Geo Washington/Shakespeare

3-object recall ______/3 at 5 minutes

Judgement - What would you do if…  There was a fire in the trashcan?  Your symptoms were getting worse? (suicidal)
Abstraction What does it mean when someone says…  People who live glass houses shouldn’t throw stones
 Don’t judge a book by its cover
 How are a fish & submarine the same  How are a desk and a bookcase the same?

Insight  What is causing the problem?  What needs to happen for life to improve?
PEDS – confidentiality statement Y/N Date: Time: Client#___________ M/F Age: Preferred name:
1. source of info 3. HPI A. Onset / duration/  sx over time B. Precipitants C. Modifying
2. CC D. Baseline function E. Associated sx

4. Mood
5. Stressors money/relationships
How is your life different because of ____________ magic wand / magic pill

6. SX A. Depression PHQ  c menses/time of year  B. GAD-7 Worrier? How long? What do you worry about? Panic attacks?
Center of attention / health or appearance / family member / leaving home / phobias C. Hallucinations? sounds, voices, other people didn’t
D. PTSD Startle easily  E. OCD checking – cleaning behaviors / need things in order / images can’t get out of mind / picking skin – pulling hair
F. Delusion Any special abilities or hear other people’s thoughts  F. Mania  sleep but still energy / start lots of projects / risk behaviors

7. Sleep Bedtime Sleep at up at noc Wakes Naps / Nightmares / Enuresis Feels rested Y/N
8. Energy Norm /  /  Is this a change? Y / N x 9.  memory? Y/N 10.  concentration? Y/N

11. What do you do for fun? Change in interest? Y/ N x

12. Appetite Norm /  /  Does food taste good to you? Y/N Weight loss / gain? Concern re wt?
Breakfast Lunch Dinner Snacks/Soda
13. Gen health Pain Y/N PCP last seen? Pharmacy
14. Medical issues Fx /head inj / sz
ROS
15. Medications Contraception / OTC / vit & herbal
NKDA?
16. LNMP Reg Y/N G P Ab 17. Surgeries

18. Labs/EKG 19. Immunizations Influenza / Pneumonia / Tetanus / Hep A/B

20. Dentist 21. Eye Dr glasses/CL – distance close

22. Where live? House/Apt/trailer Own/rent 23. Born/grew up

24. Work / military A. Current/last job B. Longest job

25. Who in house? Feel – Safe/calm/chaotic. Witness/experience abuse?

A. Chores? Do them?
26. Relationships A. problems impact relationships? B. Who in life trust & depend on? C. Friends D Keep relationships long? Y/N
E. Significant losses death/divorce? F. Get along with most people Y/N

G. Romantic Current ______mo/yr F. Quality H. longest _____ mo/yr M/F/Bi

27. Family Age Occupation Relationship- growing up/now Mental health (drug/ETOH) /med problems
A. Mom
B. Dad
C.
D. Sibs

E. Grandparents

28. EDU School___________________ Grade _____ Skip/repeat grade ______ What is school like? A. Friends B. school activities
C. Grades – Change Y/N

D. discipline problems, paying attention/sitting still E. accommodations Special ed / IEP/504 F. At / below grade level
 29. Suicide A. When is the last time you thought about suicide or death? B. Fam hx suicide
C. Past attempts What led to this?

D. Self harm? Cut/burn - location How does this help you?

30. Violence Do you have much of a temper? Y/N A. Thoughts or hx or threatening or harming someone? B. Breaking things/punching walls?
C. Argue or defy parent/teachers
D. Blame others
31. Arrests/legal issues

32. PSYCH HX
A. Out-pt therapy Y/N Who When
B. Current Meds Taking /7 days Effectiveness/SE C. Past meds

D. Hospitalizations How many in life? Past year? When? Reason? Where?

E. Drug or alcohol tx Y/N

Parent Alone – FAMILY MENTAL HEALTH ISSUES

33. Preg/Develop A. Mother’s health during preg? _________________ B. Complications with birth Vag/C-S _________________ C. Drugs Y/N
D. Planned Y/N
E. Delay in development
F. Med problem or serious injury during childhood
34. Anything you need to tell me with ____ out of the room?

Kid alone – RELATIONSHIPS WITH FAMILY

35. Worse thing ever happened to you? 36. Anything you need to tell me with ____ out of the room?
Sexually active Y/N

37. SUD A. Past tx for ETOH/drugs? 38. Total screen time

B. Friends who use ETOH/Drugs? 39. Caffeine: Coffee/tea Soda Energy
40. Ever smoked-chewed-vape-juuled Started Amnt pk/d Quit
1. ETOH 2. RX meds 3. Marijuana 4. Spice/K2 5. Opioids/narcotics 6. Meth/speed/amph/salts 7. Cocaine 8. Ecstasy (Molly/MDMA)
9. Heroin 11. Acid 12. Huffing 11. Ketamine

First use Last use Alone/Others Amnt? Increasing? Route Longest sobriety – How? Problems because of use

MSE Assess Memory & Concentration

Orientation  Where are you right now?  Year  Month  Day
3-object recall I’m going to say 3 words and want you to repeat them back. Remember them
 SPOON Something to eat with  BALL Something to play with  RED A color

Concentration  Start at 100 and subtract 7  Start at 50 and subtract 3  If something costs 78 cents and you give the cashier one
& Attention (93, 86, 79, 72, 65, 58, 51, 44) (47, 44, 41, 38, 35, 32, 29, 26) dollar, how much change should you get back? (22 cents)
 Spell WORLD backwards (or watch)  Months of the year backwards starting c Dec
Fund of  6 States border WY (CO/UT/ID/MO/SD/NE)  Presidents (Trump/Obama/Bush)
Knowledge  4 biggest cities in US NY/LA/Chicago/Houston  What was ____ famous for MLK/Geo Washington/Shakespeare

3-object recall ______/3 at 5 minutes

Judgement - What would you do if…  There was a fire in the trashcan?  Your symptoms were getting worse? (suicidal)
Abstraction What does it mean when someone says…  People who live glass houses shouldn’t throw stones
 Don’t judge a book by its cover
 How are a fish & submarine the same  How are a desk and a bookcase the same?
Insight  What is causing the problem?  What needs to happen for life to improve?
Questions
2. CC What has been different recently that led you to make an appointment?
3. HPI
A. Onset / duration/  sx over time - Chronologic timeline first started having problems OR last time perfectly well? /
how old when first sx / Every day? Worse in AM? Winter?
B. Precipitants What do you think might be causing this? C. Modifying Anything make it better? Worse?
D. Baseline function How were things going before this started? E. Associated sx What else is happening?
How do the symptoms affect your life? Magic wand / magic pill
What needs to happen for life to improve?
Willing/able to take medication 7/7 days?

27. Family
A. Any blood relative with mental health problems like depression, anxiety, bipolar disorder, psychosis, schizophrenia,
drug/ETOH dependence, odd eccentric, difficult personality
B. Any blood relative with medical problems like heart disease, diabetes, thyroid problems, cancer, seizures

29/32 Suicide
A. Do you think there is any hope? Are you planning to be here tomorrow? Next week?
B. What ways have you thought about? (cutting, pills, gas, jumping, gun, rope)
C. Have you planned it out in your mind? D. Do you have the _____ E. Prepared (note, affairs in order)
F. How close have you come? G. What has stopped you? H. Feeling suicidal now? I. Specific plan

Questions
2. CC What has been different recently that led you to make an appointment?
3. HPI
A. Onset / duration/  sx over time - Chronologic timeline first started having problems OR last time perfectly well? /
how old when first sx / Every day? Worse in AM? Winter?
B. Precipitants What do you think might be causing this? C. Modifying Anything make it better? Worse?
D. Baseline function How were things going before this started? E. Associated sx What else is happening?
How do the symptoms affect your life? Magic wand / magic pill
What needs to happen for life to improve?
Willing/able to take medication 7/7 days?

27. Family
A. Any blood relative with mental health problems like depression, anxiety, bipolar disorder, psychosis, schizophrenia,
drug/ETOH dependence, odd eccentric, difficult personality
B. Any blood relative with medical problems like heart disease, diabetes, thyroid problems, cancer, seizures

29/32 Suicide
A. Do you think there is any hope? Are you planning to be here tomorrow? Next week?
B. What ways have you thought about? (cutting, pills, gas, jumping, gun, rope)
C. Have you planned it out in your mind? D. Do you have the _____ E. Prepared (note, affairs in order)
F. How close have you come? G. What has stopped you? H. Feeling suicidal now? I. Specific plan
 Psychiatric Exam

Appearance Appearing about stated age Obese Well developed

Appears older than stated age Other Well groomed
Disheveled Overweight Well nourished
Emaciated Underweight

Gait Assisted Shuffling Unsteady

Limping Steady Walks quickly without difficulty

Muscle strength Abnormal Movements Cogwheel Rigidity Normal

& tone Atrophy Flaccid Spastic

Behavior Good eye-contact Other Psychomotor agitation

Hyperactive Poor eye-contact Tie

Attitude Aggressive Evasive Other

Cooperative Flirtatious Tense
Defensive Guarded in responses Uncooperative
Dramatic Open in offering personal information

Appropriate, calm, pleasant, relaxed / Cheerful / bright / peppy / Obsequious (servile) / solicitous / effusive (gushing) / over-inclusive /
entitled / controlling / grandious / hostile / suspicious – guarding / sullen – withdrawn / childish-regressed / antagonist – critical / angry /
irritable / indifferent / distant / aloof / vacant
LOC Alert Drowsy Other – preoccupied / distractible
Asleep Lethargic Stuporous

Orientation Able to state the day, date, name of this Behavior and speech suggest no impairment Other
place, and purpose of this interview in orientation

Speech Dysarthric slowed/slurred Normal in rate, volume, and amount Reduced in amount
Garbled Other Slow
Hard to understand Pressured Slurred
Loud Rapid Soft
Mumbled
AMOUNT (paucity / impoverished single-word answers/Loquacious /verbose/ rate / volume / fluency (no if ands and buts) / Neologisms.
ARTICULATION unclear / poor diction MODULATION loud/soft PITCH monotone SPONTANEITY latency / haulting RHYTHM stuttering /
irregular pause
Mood internal Angry Euthymic Mildly elevated
Anxious Irritable Mixed
Depressed Labile Other
Elated

Reported as REACTIVITY – mood brightens in response to positive event

Affect external Angry Inconsistent with expressed mood Other
Anxious Intense Restricted
Consistent with expressed mood Irritable Sad
Depressed Manic Tearful
Flat

Congruence between mood, appearance, & behavior

Mixed affect / labile

Thought process Circumstantial extra details Incoherent Rambling

Coherent Jargon meaningless speech Slowed
Concrete Logical Tangential never returns to topic
Confused Looseness of associations little connection Thought Derailment sudden halts
Flight of Ideas between ideas Word Salad no syntax (rules)
Fragmentation Perservative
Racing

Goal directed. SEVERITY circumstantial  tangential  flight of ideas  rambling  loose associations  thought blocking  derailment 
fragmentation verbigeration continuous repeating random words  word salad
Thought content Delusions Nihilistic (non-existence of self) Other
Grandiose No signs of psychotic thought processes Overvalued Ideas less bizarre/firmly
Hyper-religious Obsessions held
Ideas of Reference Phobias
DELUSIONS (bizarre/non-bizarre) paranoid, grandiose, jealous, erotomanic, somatic, passivity/control spend a lot of time thinking about 1
or 2 things? / How do you know this? / How did this start? / why would someone want to do this? Preserved insight know it is unlikely
mood congruent themes that fit mood disorder (worthless/brilliance)
Egosyntonic not foreign or distressing
OBSESSIONS repetitive thoughts can’t stop? Thoughts feel like they are your own? Forced to think about things against your will?
Preoccupations / Ruminations - willful
Perceptual Appears to be responding to internal Olfactory hallucinations Tactile hallucinations
disturbances stimuli Other Visual hallucinations
Auditory hallucinations
No perceptual disturbances

Suicidal/homicidal Active suicidal ideation Other Suicidal intent

thinking None Passive suicidal ideation Suicidal plan

Future oriented thinking SI without plan or gesture. What is it that keeps you here? (keeps you from killing self?) feeling suicidal now?
Specific plans to hurt yourself? How would you do it?
Insight/attitude Blames others for the current problems Limited, but appropriate for developmental Recognizes a mental health problem
towards tx level
Does not believe there is a problem of Recognizes there might be a problem but is
any significance Other reluctant to agree with me on what it is

Recognizes type of help needed to address problem

INTACT (FULL) modifies behavior / cooperative c tx / PARTIAL Aware of ___ but unable to apply it to further experiences / choose safe
actions / contemplate before acting / list pros and cons to action / ABSENT No capacity to understand concerns of others / poor
adherence or follow-through with tx

Judgement At this time appears to be intact Poor as a function of current mental state Poor as a function of stable traits

APPRAISING CHALLENGE / SURVEYING & WEIGHING ALTERNATIVES / MAKES COMITTMENT TO CHOICE

INTACT As evidenced by - response to question… besides ___ what else could you do when ____
POOR As evidenced by impulsivity / engaging in actions with high probability for damaging consequences such as ___
Attention & Able to spell "WORLD" backward Serial 3 subtraction from 100 Serial 7 subtraction from 100
concentration Easily Distracted
Able to attend to discussion/questions
Recent & remote Able to recall three unrelated words at Not formally assessed, but there are no signs Other
memory five minutes of memory impairment based on this “spoon/ ball / red”
interview
_ / 3 words at 5 minutes

Intelligence Estimated intelligence = Above average Estimated intelligence = Below Average Other
functioning and Estimated intelligence = Average
fund knowledge Based on vocabulary /personal knowledge
Based on fund of knowledge - presidents / largest cities / states that border WY
EPS (early onset) Has signs of EPS No evidence of EPS Rhythmic/repetitive/random/voluntary/involuntary /  with…
Akathisia – hours to weeks (subjective) inner restlessness
Tardive dyskinesia Has evidence of tardive No evidence of involuntary  MOVEMENTS:
(late onset) dyskinesia movements
- Athetoid – slow, writhing, twisting
- Ballismus – (fast, violent athetoid)
Increased chance TD -  age / F / duration /  dose / drug
- Choreiform – irregular, jerky, spasmotic (quasi-purposful)
holiday
- Stereotypies—repetitive, rhythmic – Tics/vocalizations
DYSTONIA - hours to days (torticollis / blepharospasm / laryngospasm)
HYPOKINETIC
Ataxia (disorganized walk)
Akinesia/bradykinesia days to weeks – can’t move muscles (parkinsonian)
Other Secondary gain
DEPRESSION DSM p. 160 (94). PHQ-9A = 5-9 mild / 10-14 mod / 15-19 mod-severe / 20-27 severe
What do sx interfere with? Could you watch an entire TV show? Read a book? Article? Newspaper?
Sx worse in AM or night worse in am = melancholic features. Does your mood lift when something good happens?
PREMENSTRUAL DYSPHORIC DISORDER White book p. 46. DSM p. 171 (100). Seasonal pattern p. 187 (113)
Any problems around the time of your period? / Worse in winter?
MDD DSM p. 160 (94) – Last 2 weeks / almost every day / must include 1 or 2 / > 5 sx
1. Depressed Mood 2. Loss of 3.  in appetite or wt; 4. Insomnia or hypersomnia; 5. Psychomotor agitation or retardation
(irritability in peds) interest/pleasure (observable); 6. Fatigue; 7. Worthlessness or guilt; 8. Impaired concentration or indecisiveness;
9. Thoughts of death or SI

PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) DSM p. 168 (97)

Depressed mood most of the day for more days than not > 2 yr adults (irritability in peds > 1 yr)
+2 other sx: 1.  appetite; 2. Insomnia/hypersomnia; 3. Fatigue; 4.  self-esteem; 5. Impaired concentration or indecisiveness 6. Hopeless

BIPOLAR White book p. 32-35 DSM p. 123 (65) / Mood Disorder Questionnaire Yes to #1 - 7/13 Yes to #2 Mod-serious #3
Ever had a week or so when you felt so good you didn’t need to sleep  friends said you were talking too fast or acting strangely 
During this time did you start lots of projects or do more risky things (spend money / sleep around?)  What was the longest you
went without sleep?  Snapping or getting into arguments?  So many ideas you could hardly keep up?  Especially confident? 
any great ideas or plans?  hard to stop talking?  use your phone more than usual?  easily distracted (anything could get you off
track)?  hard to sit still?  feel physically restless?  Did things that caused you or your family problems?
MANIA distinct period 1 wk / marked impairment +3 (+4 if mood only irritable) -  self-esteem (grandiosity); Talkative
HYPOMANIA 4 days (most days, nearly every day) /  impairment (pressured); Flight of ideas; Distractible;  activity; Risk taking

ANGER / IRRITABILITY Do you have trouble controlling your temper?  What does an outburst look like? How often?
Constant irritable/bad mood = Disruptive mood dysregulation DSM p. 156 (93) by age 10
Argue / disobey / irritate / blame others / vindictive = Oppositional defiant disorder DSM p. 462 (219)
Out of proportion to situation? (> age 6) = Intermittent explosive white p. 76 / DSM p. 466 (220)  Are outbursts planned? Gained?
Conduct Disorder p. 469 (221) (> 18 = antisocial PD)  bullies or threatens  weapon  physical fights  Destruction of property?
Fire / deliberate  Theft / cons other  Ran away? Skipped school? 

OCD White book p. 68 DSM p. 237 (129) Do you have any symptoms of OCD How long does it take you to leave the house?
Order – arranging room, counting, saying something special Image someone will break in / you will hurt someone
Behavior wash your hands, repeatedly check things (door locked, stove off) Other: Body dysmorphic / Trich / Excoriation

PSYCHOSIS White book p. 31 DSM p, 99 (50) Heard noises, sounds, voices other people didn’t hear?
Inside or outside your head? Outside more likely hallucinations If Inside But you hear it with your ears?
When did they start?  Hear them every day? (how often or what time)  How many voices?  M/F?  Do you recognize them?
 Voices ever talk to each other?  Do they talk about what you are doing? Or thinking? (is it like a sports announcer?)
Do they tell you to do anything?  Saying bad things about you or someone else?  Flashes of light, flames, geometric figures?
Full sentences? Full sentences supports schizophrenia rather than drugs or med
Negative sx Avolition: sit for long periods / Asociality: lack of social interest / Ahedonia: decreased pleasure / Alogia: less talkative
Delusions White book p. 2 Any special abilities or importance that others don’t have?  Can you hear other people’s thoughts or
can they hear yours?  Are people are watching, talking about you, or out to get you?  TV/radios ever talk specifically to you?
Conviction. How convinced are you of these ideas/beliefs? Are you certain your ideas are accurate? WHY?
Perception of others. What do you think other people (would) think of your beliefs? [PAUSE] Would most people think your beliefs
make sense? Insight What do you think has caused you to have these beliefs?

ADHD Any problems with paying attention or not being able to sit still? Some sx present before 12 / several settings
If you have some money will you spend it? What does your room look like? / Any trouble finishing big projects? / People say you don’t listen? /
Blurt things out?/ Think things out – or impulsive? “watch this” / Forgetful (lose keys / phone / appointments) / manage time well?
Inattention 6+ (kids) 5+ (adults) >6 mo Organization: Problems finishing tasks; Can’t organize tasks; Loses things Attention: Poor focus;
Forgetful; Easily distracted; Careless mistakes; Doesn’t listen to spoken directions; Avoids tasks requiring concentration.
Hyperactivity 6+ (kids) 5+ (adults) >6 mo Impulsivity: Can’t play quietly; Problems waiting for turn; Talks too much; Blurts out answer;
Interrupts Movement excess Fidgets/squirms; Leaves seat; Driven by motor; Active when inappropriate (adult=restless)
ANXIETY White GAD p. 56 / Panic p. 48 / agoraphobia p. 50 GAD-7 = 5 mild / 10 moderate / 15 severe
Are you a worrier?  What do you worry about?  Worry something bad will happen?  How does worrying help you?  How
much time do you spend worrying each day?  What does worrying stop you from doing?
GENERALIZED ANXIETY DISORDER (GAD) DSM p. 222 (122) A. Worry re multiple things for > 6 mo AND B. Can’t control the worry
C. 3+ additional sx (1+ in peds): 1. Restlessness/on edge; 2. Easily fatigued; 3. Difficulty concentrating / mind blank; 4. Irritability; 5. Muscle
tension; 6. Sleep disturbances

Panic Ever had a panic attack? What was it like? What were you doing? How long last? How many have you had?
Anything cause them or out if the blue?  Change your routine or behavior after these began?  Other sx – SOB or smothered,
choking / heart racing- palpitations, chest pain or tightness / nausea, sweating or chills, numbness/tingling lips, fingers or toes / feel
like you are about to die, lose control, or go crazy / dizzy or lightheaded / feel unreal or in a dream or watching from outside yourself
Social Ever uncomfortable in social situations? Center of attention Public speaking, questions in class, party/meeting
How uncomfortable does this make you? (panic attack?)  Do you try to avoid social situations?
Agora Get anxious when you leave home? Crowds, busses, stores, restaurants, bridges, open places, being alone?
What is it about ___ that worries you?  What is the worst thing that can happen?  What do you do to cope?
SOCIAL ANXIETY DISORDER DSM p. 202 (118) AGORAPHOBIA DSM p. 217 (121)
A. Fear of scrutiny by others peds must A. Fear re 2 + situations: 1. Public transportation; 2. Open spaces; 3. Enclosed places; 4.
include peer setting; B. Fears embarrassing Standing in line or in crowd; 5. Being outside the home alone;
self or offending others B. Afraid escape difficult or help not available if panics or other embarrassing problems
C. Situation consistently causes fear/anxiety; D. Situation avoided or endured with fear; E. Out of proportion to threat; F. Persistent (>6 mo)

Separation Feel anxious when away from home or a certain family member? Worry about losing them or something bad could
happen to them? Lost, kidnap  Willing to go to school?  Can you sleep without them  OK to be home without them?  Physical
sx if separated HA, nausea, vomiting
SEPARATION ANXIETY DISORDER DSM p. 190 (115)
A. Fear of separation from loved ones (not commensurate with normal development) > 1 mo if ped / > 6 mo adult
3 + sx: Anxiety when: a. Separating from home or loved ones; b. Leaving home when it causes separation; c. Sleeping away (different room)
from loved ones Among with feelings of: a. Worry about harm to loved ones; b. Worry about separation (even if not impending); c. Fear about
isolation from loved ones Including: a. Nightmares; b. physical sx (HA, stomachache, N/V)

Phobia Any special fears? Spiders, snakes, insects Does it cause panic attack? DSM p. 197 (116)
Somatic Do you worry a lot about your health? White book p. 80 DSM p. 311 (161) Frequent HA, stomachache or other problems/
worried about getting sick  Unexplained aches & pains? / worried illness not being taken seriously?  Think about this a lot?
Body dysmorphic Anything about your physical appearance you worry a lot about? White book p. 72 DSM p. 242 (131)
Eating Ever thought you had an eating disorder like anorexia or bulimia? White p. 8 DSM - Anorexia 338 (171) / bulimia 345 (172)
Ever thought you were overweight? Gone on a diet? Ever felt like your eating was out of control?  Eating binges where you ate a
large amount of food or couldn’t stop eating? – Vomited or laxative?

PTSD White p. 58 Startle easily?  PTSD – Repeated, distressing memories, dreams, or flashbacks of something from your past?
Do you avoid things that you associate with this memory?  NEGITIVELY negative view of self/world depression sx
 ARROUSAL – insomnia, difficulty concentrating, irritability, hypervigilance?  blanking on what happened?
POSTTRAUMATIC STRESS DISORDER DSM p. 271 (143) > 1 mo / if < 1 mo - acute stress  Derealization  Depersonalization (outside body)
Re-experience 1+/5 Dreams; Flashbacks; Memories; Physical distress to cues; Psychological distress to cues
Avoidance 1+/2 Memories/thoughts; reminders (places/ people / objects
Cognition or mood 2+/7  interest; Negative emotions; Lack of positive emotions; Amnesia; Detachment; Blame self; blame others;
Negative view others/self/world “ruined forever”
Arousal / reactivity 2+/6 Irritable/Angry; Reckless/Self-destructive; Concentration; Hypervigilance;  startle; Sleep problem

SUBSTANCE USE DISORDER 2+/11 in 12 mo period. DSM p. 490 (233)

Larger amounts/more than intended; Desire to cut down or control use; Failure to meet role at home/work;  time obtaining / recovering;
Recurrent / persistent social problems; Known physical/psych problem; Gives up social/recreational activities; Craving; Tolerance; Use in
situations physically hazardous; Withdrawal
I am going to ask you some question that may seem odd but may fit some personal experiences we haven’t spoken
about.
Paranoid Mst common – people “Is anyone trying to hurt you, following you, or spying on you?”
harassing / trying to kill /
spread rumors
(or ideas) of other people / TV / - Do you feel like strangers look at you a lot or talk about you?
Reference newspaper referring to - Have you ever felt like the TV or radio was talking just to you or giving
them you special messages?
Control / Controlled by an outside - Do you ever feel you are not in control of your own ideas or thoughts?
Influence force
Replacement Important people in life
(Capgas) replaced
Jealousy Spouse is unfaithful
Somatic Illness / being poisoned - Are you worried about any serious problems with your body or
diseases?
- Do you think someone has been trying to poison you?
Grandiose Special powers / will - Do you have any special talents or abilities most people aren’t given?
accomplish great things - Any special importance?
(Religious / technological – - Any special religious powers or abilities?
connected to computers) - Any special technology abilities or powers?
Thought People know your thoughts - Do you ever think of things so strongly people can hear your
broadcasting thoughts?
Thought Thoughts taken out of your - does anyone ever interrupt, steal, or remove thoughts out of your
withdrawal mind – lead to thought head?
blocking
Thought Thoughts put into your - Do you ever feel like your thoughts are not your own, but inserted by
insertion head someone else?
Guilt Common in depression - Do you think you have done anything terrible and need to be
punished?
 ADHD
INATTENTION - What does your room look like?

A. Lacks attention to detail/careless mistakes

 Do you often make careless mistakes in schoolwork? How often? Does it affect your grades?
 Do you make mistakes while doing chores or playing games?

B. Difficulty sustaining attention

 Is it hard to focus on just one thing for a long time?
 Even when it’s fun?
 Is it hard to focus on a test or assignment that lasts an entire period?

C. Does not seem to listen when spoken to

 Do you have trouble focusing on what people are saying to you (even if they are talking directly to
you)?
 Do your teachers or mom ever say you don’t listen

D. Poor follow through

 Trouble completing things? (start doing things and leave in the middle)
o Told to put your shoes on / setting table

E. Difficulty with organization

 What does your room look like?
 Trouble organizing schoolwork?
 Do you need your mom’s help in organizing schoolwork / projects?

F. Avoids tasks requiring sustained mental effort

 Do you hate doing homework or projects because it’s hard to concentrate?
 Do you put off doing projects that take a lot of concentration?

G. Loses things
 Do you lose thigs a lot? (phone / keys / money)

H. Easily distracted
 Is it hard to pay attention when things are going on around you? What distracts you?

I. Forgetful
 Are you forgetful in everyday things like doing chores / appointments?
 Do you forget to do things like brush your teeth / wash hands / changing underwear? How much is
forgetfulness and how much is not liking to do it?

HYPERACTIVITY/IMPULSIVITY
Do you usually think things out before doing them or just go ahead and do it? Are you a saver or spender?

A. Fidgets
 Is it hard for you to sit still?
 Can you sit still for a whole class? Doing homework? Movie? Playing a game?
 B. Difficulty staying in seat (at school / for a meal)

C. Runs/climbs excessively (restless in adolescents)

 Do you get in trouble at school or home for climbing on things / Jumping down stairs / running
down the hall /

D. Difficulty engaging in quiet activities

 Do you get told to play quieter?
 Is he/she noisier than other kids their age?

E. On the go” / driven by a motor

 Is it hard to just sit still?
 Do you have trouble unwinding or relaxing when you have time?

F. Talks excessively
 Do you talk a lot? More than other kids?
 Parents or teachers say you never stop talking?

G. Blurts out answers before question completed

 When your teacher asks a question do you sometimes blurt out an answer before they are finished
asking? Has your teacher talked to your parents about this?
 Do you finish other people’s sentences?

H. Difficulty awaiting turn

 Is it hard for you to wait your turn while playing a game or in line
 Hard to wait at a restaurant

I. Interrupts
 Do your parents / teachers get frustrated at you for interrupting them when they are talking or
busy?
 Do other kids tell you to leave them alone so they can do their work?
 Do you ever butt into other kids games without being asked?

6 ITEM ADULT ADHD SCREENING

1. How often do you have difficulty concentrating on what people say to you, even when they are
speaking to you directly?
2. How often do you leave your seat in meetings or other situations in which you are expected to remain
seated?
3. How often do you have difficulty unwinding and relaxing when you have time to yourself?
4. When you’re in a conversation, how often do you find yourself finishing the sentence of the people you
are talking to before they can finish it themselves?
5. How often do you put things off until the last minute?
6. How often do you depend on others to keep your life in order and attend to details?
 ADHD
INATTENTION

A. Lacks attention to detail/careless mistakes

B. Difficulty sustaining attention
C. Does not seem to listen when spoken to
D. Poor follow through
E. Difficulty with organization
F. Avoids tasks requiring sustained mental effort
G. Loses things
H. Easily distracted
I. Forgetful

HYPERACTIVITY/IMPULSIVITY

A. Fidgets
B. Difficulty staying in seat (at school / for a meal)
C. Runs/climbs excessively (restless in adolescents)
D. Difficulty engaging in quiet activities
E. On the go” / driven by a motor
F. Talks excessively
G. Blurts out answers before question completed
H. Difficulty awaiting turn
I. Interrupts

SUICIDE Carlat pp 162-163

When is the last time you thought about suicide? How do you see your future?
Are you feeling suicidal right now?  Are you planning to be here tomorrow?  Do you have any specific plans?
What keeps you from killing yourself?  How close have you come?  Written a note? Pills, hanging, shooting, cutting
ADULT – confidentiality statement Y/N
Date: Time: Client#__________ M/F Age: Preferred name:

1. CC - What has been different recently that led you to make an appointment?
If there was a perfect medication that would help you, what would it do?

2. HPI
Onset (first started having problems / last time perfectly well? / how old when had first sx)

Duration

Timing / Persistence (Every day?) (Worse in AM? Winter?)

Precipitants (anything you think caused it?) / Modifying (anything make it better?)
How were things going before this started?

3. One word to describe your mood in the last week?

How would a friend who knows you describe your recent mood?

4. VEGETATIVE
A. Sleep
Time go to bed Sleep at noc waking wake up feel rested Y / N

Naps Nightmares? Nocturia

Energy despite not sleeping?

B. Appetite Norm/  /  Weight loss / gain? Does food taste good to you? Y / N
Breakfast Lunch
Dinner Snacks
Drinks

C. Energy level Is this a change? Y / N x

D. What do you do for fun

Change in interest? Y/ N x
E. Exercise

F. Changes in your memory? Y/N G. Concentration? Y/N

H. Stressors? I. Pain? Y/N
5. PERSONAL/SOCIAL/EDUCATION HISTORY

A. Where living – City ____________ Apt/house/tailer own/rent

B. Who with?
C. Born: Raised:
D. Who in house growing up?
E. Losses- death/divorce?
E. Get along c parents? Y/N What do if you disobeyed?
F. Get along c sibs? Y/N
G. Preg/Develop
Planned pregnancy? Y/N Stress during preg?
Medical prob in preg? Y/N Vag/C-sect Normal develop? Y/N
H. Relationships: do you have people in your life you can trust and depend on? Y/N
Is problem affecting relationships? Y/N
Friends Keep friends long Y/N

Partner – Romantic relationship? Y/N Length? _____ Quality of relationship ________

Sexually active Y/N M/F/Bi Sexual problems Y/N
Married/Divorced Kids?

I. Level of education Current grade:

What is/was school like for you? (friends / discipline problems / school activities )
Problems paying attention in school or hyperactivity?
Grades?
J. Type work Last job Longest job
K. Military service:
L. Arrest / Legal problems
M. ACE What’s the worst thing that has ever happened to you?
Did you ever feel mistreated as a child? / was growing up a safe time in your life? / any abuse or trauma

N. Violence to someone else?

O. Cultural / spiritual beliefs
P. What do you like best about yourself?

Q. Anything about yourself that needs to change? (temper / anxiousness)

6. PSYCH HX
A. Current mental health dx Past mental health dx

B. What medications have you tried? How long did you take the medication? Taking ____ days / 7
Good Dates – why stopped Bad Dates – why stopped

C. Therapy?

D. Hospitalizations (how many in life? Past year? Date of last? What things hospitalized for?)

E. When is the last time you thought about suicide or death? Self harm? How does that help you?

F. Past hx suicide attempts / self harm / harming others (cutting?) What led to this?

7. MED HX How is your general health?

LNMP (regular?) ___________ G____ P___ Infections? HIV / STDs?
A. Current meds: (contraception)

B. Over the counter, vitamins, or herbal products?

C. Any allergies/reactions to medications?
D. Who do you see for your medical care? Last visit
Last lab testing
EKG
E. Immunizations - Influenza Pneumonia Tetanus Hep A/B
F. Last time you saw dentist
G. Last time you saw eye dr Glasses/CL - distance/close Hearing test
H. Fx /head inj / sz I. Surgeries?

8. FAMILY HX depression / anxiety / psychosis or schizophrenia / drug or alcohol dependence, suicide or suicide
attempts, mental hospitalization, or arrests or incarcerations? Any relatives who were considered odd or eccentric or
who had difficult personalities?”
A. Mom
B. Dad
C. Bro D. Sis
E. Mat grandma
F. Mat grandpa
G. Pat grandma
H. Pat grandpa
I. Kids
9. SUBSTANCE USE
A. Were you ever treated for the use of alcohol, drugs?

B. What happened as a result of treatment?

C. Caffeine - coffee /tea Soda energy drink

D. Ever smoked? Y/N started age ______ pks/d Quit

Chewing tobacco Vaping

E. Alcohol how often do you have a drink?

F. Ever use prescription medications not prescribed for you /differently than they have been prescribed Y/N

What types of drugs do you use – like marijuana / LSD / cocaine / opioids
Age first use How often Alone/Others Last time used Longest sobriety - how
Marijuana:
Meth/speed / amph:
Opioids / narcotics:
Mushrooms:
Huffing:
Ketamine:
Spice:
Acid:
Molly (MDMA / Ecstasy)
Bath salts:
Heroin:
Cocaine:

ROS
I’d like to switch gears a bit and ask you about some common symptoms
1. Depression 2. Bipolar 3. Anxiety 4. OCD 5. ADHD 6. Eating 7. Somatic
8. Schizophrenia. 9. Dementia
MSE
I’d like to ask you some questions to assess your memory and concentration

Orientation
 Where are you right now?  Year  Month  Day
3-object recall I’m going to say 3 words and want you to repeat them back. Remember them because I’m
going to ask you for them again in a few minutes
 Spoon – something to eat with  Ball - Something to play with  Red – a color
Concentration/attention
 Start at 100  Start at 50 and  If something costs 78 cents and you give the cashier
and subtract 7 subtract 3 one dollar, how much change should you get back?”
(93, 86, 79, 72, 65) (47/44/41/38/35)
 Spell WORLD backwards (or watch)  Months of the year backwards starting c Dec
Fund of Knowledge
 Presidents (Trump/Obama/Bush)  What was ____ famous for MLK/Geo Washington
 6 States border WY (CO/UT/ID/MO/SD/NE)  4 biggest cities in US NY/LA/Chicago/Houston

Retest 3-Item Recall. ___/3 at 5 minutes

Judgement What would you do if…

 There was a fire in the trashcan?  You found a stamped addressed envelope on the
ground?
 What should you do when you notice your  What would you do if you actively became
symptoms are getting worse? suicidal?
Abstraction What does it mean when someone says…
 People who live glass houses shouldn’t  Don’t judge a book by it’s cover
throw stones
 How are a fish & submarine the same?  How are a desk and a bookcase the same?
Insight
 Do you think there’s anything wrong?  What needs to happen for life to improve?
 What will happen if you don’t follow through with treatment?
Med check
Date: Time: Client#__________ M/F Age: Pharmacy:

Last seen: Therapy Y/N with: Frequency: weekly/______

1. Allergies:
2. Current meds:

Taking ____ / 7 days

3. Satisfaction How’s medication working?

4. SE - Denies lightheadedness/dizziness/parathesias/muscle weakness/recent falls. Denies nausea /vomiting

/diarrhea/or constipation.

A. Other side effects:

B. Satisfaction with meds:

C. New medical prob:

5. Constitutional
Sleep Appetite
Energy Pain
Stressors Substance

6. Symptom screening: A. Panic B. Anxiety C. Depression D. PTSD E. Mania F. Delusional thinking

G. Hallucinations H. Repetitive thoughts/behaviors. I. SI/HI:

7. Med hx:

8. Psych hx:

9. Plan
A. Continue:

B. Change:

D. Refill:

E. Labs:

F. Therapy Continue/meds only

G. RTC:
If problems, call 637-3953 and ask for RN / If in crisis, call 911 or go to ER immediately
PED – confidentiality statement Y/N
Date: Time: Client#__________ M/F Age: Preferred name:

1. CC - What has been different recently that led you to make an appointment?
If there was a perfect medication that would help you, what would it do?

2. HPI
Onset (first started having problems / last time perfectly well? / how old when had first sx)

Duration

Timing / Persistence (Every day?) (Worse in AM? Winter?)

Precipitants (anything you think caused it?) / Modifying (anything make it better?)
How were things going before this started?

3. One word to describe your mood in the last week?

How would a friend who knows you describe your recent mood?

4. VEGETATIVE
A. Sleep
Time go to bed Sleep at noc waking wake up feel rested Y / N

Naps Nightmares? Nocturia

Energy despite not sleeping?

B. Appetite Norm/  /  Weight loss / gain? Does food taste good to you? Y / N
Breakfast Lunch
Dinner Snacks
Drinks
C. Energy level Is this a change? Y / N x

D. What do you do for fun?

Change in interest? Y/ N x
E. Exercise
F. Changes in your memory? Y/N G. Concentration? Y/N
H. Stressors? I. Pain? Y/N
5. PERSONAL/SOCIAL/EDUCATION HISTORY
A. Where living – City ____________ Apt/house/tailer own/rent
B. Born: Raised:
C. Who in house? Own room Y/N
D. Losses- death/divorce? Custody M/D/S
E. SCHOOL Current grade: School: Reg – special classes / IEP/ 504
Standardized testing – Grade level/below Skipped/repeated grade
Recent change in grades Y/N Failing classes _____________ Missed classes Y/N
After school activities: Hours day computer/games/phone

Discipline (suspension / principal’s office) Arrests / legal?

F. Type work Last job Longest job

G. Plans after grad

H. Cultural / spiritual beliefs
I. What do you like best about yourself?

J. Anything about yourself that needs to change? (temper / anxiousness)

6. PSYCH HX
A. Current mental health dx Past mental health dx

B. What medications have you tried? How long did you take the medication? Taking ____ days / 7
Good Dates – why stopped Bad Dates – why stopped

C. Therapy?

D. Hospitalizations (how many in life? Past year? Date of last? What things hospitalized for?)

E. Were you ever treated for the use of alcohol, drugs?

F. What happened as a result of treatment?

G. When is the last time you thought about suicide or death? Self harm? How does that help you?

H. Past hx suicide attempts / self harm / harming others (cutting?) What led to this?

7. MED HX How is your general health?

LNMP (regular?) ___________ G____ P___ Infections? HIV / STDs?

A. Current meds: (contraception) Pharmacy

B. Over the counter, vitamins, or herbal products?

C. Any allergies/reactions to medications?
D. Who do you see for your medical care? Last visit
Last lab testing
EKG
E. Immunizations - Influenza Pneumonia Tetanus Hep A/B
F. Last time you saw dentist
G. Last time you saw eye dr Glasses/CL - distance/close Hearing test
H. Fx / head inj / sz I. Surgeries?

8. PARENT ALONE send out with cross-cutting sx

A. Preg/Develop
Planned pregnancy? Y/N Stress during preg?
Medical prob in preg? Y/N Vag/C-sect Normal develop? Y/N
B. Parents work – Mom: Dad:
C. Primary caregiver. M/D/S
D. Stresses at home?
E. Prob (temper tantrums/arguing/drug use)

9. FAMILY HX depression / anxiety / psychosis or schizophrenia / drug or alcohol dependence, suicide or suicide
attempts, mental hospitalization, or arrests or incarcerations? Any relatives who were considered odd or eccentric or
who had difficult personalities?”

A. Mom
B. Dad
C. Bro D. Sis
E. Mat grandma
F. Mat grandpa
G. Pat grandma
H. Pat grandpa

10. Anything you felt you couldn’t tell me about with ___ in the room?
11. Any concerns or preferences with medication?
12. KID ALONE send out with cross-cutting sx
 A. Get along c parents? Y/N What happens if you disobeyed?
B. Get along c sibs? Y/N
C. Relationships: do you have people in your life you can trust and depend on? Y/N
Is problem affecting relationships? Y/N
Friends Keep friends long Y/N

Partner/Romantic relationship? Y/N Length? _____ Quality of relationship ________

Sexually active Y/N M/F/Bi Sexual problems Y/N
Married Y/N Kids?

D. Safe at home Y/N Safe at school (bullying) Y/N

E. Anything you felt you couldn’t tell me about with ___ in the room?
F. ACE What’s the worst thing that has ever happened to you?
Did you ever feel mistreated as a child? / was growing up a safe time in your life? / any abuse or trauma
G. Current stressors
H. Violence to someone else?
13. SUBSTANCE USE
A. Caffeine - coffee /tea Soda energy drink

B. Ever smoked? Y/N started age ______ pks/d Quit

Chewing tobacco Vaping

C. Alcohol how often do you have a drink?

D. Use prescription medications not prescribed for you /differently than they have been prescribed Y/N

What types of drugs do you use – like marijuana / LSD / cocaine / opioids
Age first use How often Alone/Others Last time used Longest sobriety - how
Marijuana:
Meth/speed / amph:
Opioids / narcotics:
Mushrooms:
Huffing:
Ketamine:
Spice:
Acid:
Molly (MDMA / Ecstasy)
Bath salts:
Heroin:
Cocaine:
MSE
I’d like to ask you some questions to assess your memory and concentration
Orientation
 Where are you right now?  Year  Month  Day
3-object recall I’m going to say 3 words and want you to repeat them back. Remember them because I’m
going to ask you for them again in a few minutes
 Spoon – something to eat with  Ball - Something to play with  Red – a color
Concentration/attention
 Start at 100  Start at 50 and  If something costs 78 cents and you give the cashier
and subtract 7 subtract 3 one dollar, how much change should you get back?”
(93, 86, 79, 72, 65) (47/44/41/38/35)
 Spell WORLD backwards (or watch)  Months of the year backwards starting c Dec
Fund of Knowledge
 Presidents (Trump/Obama/Bush)  What was ____ famous for MLK/Geo Washington
 6 States border WY (CO/UT/ID/MO/SD/NE)  4 biggest cities in US NY/LA/Chicago/Houston

Retest 3-Item Recall. ___/3 at 5 minutes

Judgement What would you do if…
 There was a fire in the trashcan?  You found a stamped addressed envelope on the
ground?
 What should you do when you notice your  What would you do if you actively became
symptoms are getting worse? suicidal?
Abstraction What does it mean when someone says…
 People who live glass houses shouldn’t  Don’t judge a book by it’s cover
throw stones
 How are a fish & submarine the same?  How are a desk and a bookcase the same?
Insight
 Do you think there’s anything wrong?  What needs to happen for life to improve?
 What will happen if you don’t follow through with treatment?

BRING BACK IN PARENT - ROS

1. Depression 2. Bipolar 3. Anxiety 4. OCD 5. ADHD 6. Eating 7. Somatic
8. Schizophrenia. 9. Dementia
Other questions ROS
PHOBIAS objects or situations make you anxious if you can’t avoid? Do you make a special effort to avoid
certain objects or situations?
SOCIAL PHOBIA Fears about being humiliated in public? Doing something embarrassing in front of others?
AGORAPHOBIA Special arrangements to be comfortable to leave house? Need someone with you?
MANIA / HYPOMANIA During time your mood was so high Do things unusual for you like get into legal
trouble, spend a lot of money at once, lots of sex? People around you said you were acting different (talking
fast)
PERCEPTUAL DISTURBANCES Seen something others don’t see? heard a voice from someone not in the room?
(whose voice was it? / voice tell you to do something?)
Finish
Anything else I haven’t asked?
DEPRESSION DSM p. 160 (94) – Last 2 weeks / almost every day / must include 1 or 2 / > 5 sx
1. Depressed Mood (can be irritability in peds) 2. Loss of interest/pleasure
3.  in appetite or wt; 4. Insomnia or hypersomnia; 5. Psychomotor agitation or retardation (observable); 6. Fatigue;
7. Worthlessness or guilt; 8. Impaired concentration or indecisiveness; 9. Thoughts of death or SI

PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) DSM p. 168 (97)

Depressed mood most of the day for more days than not > 2 yr adults (can be irritability in peds > 1 yr)
+2 other sx: 1.  appetite; 2. Insomnia / hypersomnia; 3. Fatigue; 4.  self-esteem; 5. Impaired concentration or
indecisiveness 6. Hopelessness

SPECIFIERS DSM p. 184 (107-114)

Anxious Distress – 2+ 1. Keyed up or tense; 2. Restless; 3. Trouble concentrating because of worry; 4. Fear something
bad may happen; 5. Feeling might lose control of self
Severity: Mild 2 / Mod 3 / Mod-severe 4-5 / Severe 4-6 c motor agitation risk suicide /  speed /effectiveness of tx
Mixed features – 3+ 1. Elevated, expansive mood; 2. Inflated self-esteem; 3. Pressured speech; 4. Flight of ideas;
5.  energy / goal directed activity Observable by others and represent a change from norm
Melancholic Features - 1. Loss of pleasure (almost all activities) OR 2. Loss of reactivity to pleasurable events
AND 3+ additional 1. Empty mood (deep despair); 2. Sx. worse in AM; 3. Early awakening (2 + hrs); 4. Marked
psychomotor changes; 5.  appetite or wt; 6. Excessive guilt
Atypical Features – Mood reactivity and 2 + 1.  wt or appetite; 2. Hypersomnia; 3. Leaden paralysis; 4. Long hx of
personal rejection sensitivity leading to social or job impairment

BIPOLAR
GENERALIZED ANXIETY DISORDER (GAD) DSM p. 222
A. Anxiety and worry about multiple everyday things for > 6 mo B. Can’t control the worry
C. 3+ additional sx (1+ in peds): 1. Restlessness / on edge; 2. Easily fatigued; 3. Difficulty concentrating / mind going
blank; 4. Irritability; 5. Muscle tension; 6. Sleep disturbances

SOCIAL ANXIETY DISORDER DSM p. 202 AGORAPHOBIA DSM p. 217

A. Fear of scrutiny by others peds A. Fear re 2 + situations: 1. Public transportation; 2. Open spaces; 3. Enclosed
must include peer setting; B. Fears places; 4. Standing in line or in crowd; 5. Being outside the home alone;
embarrassing self or offending others B. Afraid escape difficult or help not available if panics or other
embarrassing problems
C. Situation consistently causes fear/anxiety; D. Situation avoided or endured with fear; E. Out of proportion to threat;
F. Persistent (>6 mo)

SEPARATION ANXIETY DISORDER DSM p. 190

A. Fear of separation from loved ones (not commensurate with normal development) > 1 mo if ped / > 6 mo adult
3 + sx: Anxiety when: a. Separating from home or loved ones; b. Leaving home when it causes separation; c. Sleeping
away (different room) from loved ones
Among with feelings of: a. Worry about harm to loved ones; b. Worry about separation (even if not impending); c.
Fear about isolation from loved ones
Including: a. Nightmares; b. physical sx (HA, stomachache, N/V)

POSTTRAUMATIC STRESS DISORDER DSM p. 271

A. Exposure to actual or threatened death, injury, or sexual violence
B. 1 + sx 1. Recurrent, involuntary, and intrusive memories, dreams, dissociative reactions (flashbacks), psychological
or physiological distress to cues that symbolize or resemble aspect of trauma
C. Persistent avoidance of memories or external reminders of trauma
D. Negative alterations in arousal or reactivity demonstrated by (2+): 1. Inability to recall aspects of event; 2. Negative
beliefs about self or others; 3. Distorted cognitions causing blame to self or others; 4. Persistent neg emotional
state (fear, anger, shame); 5.  interest in activities; 6. Feeling of detachment from others; 7. Lack of positive
emotions
E. Persistent change in arousal/reactivity demonstrated by (2+): 1. Irritable / angry; 2. Reckless or self-destructive; 3.
Hypervigilance; 4.  startle; 5. Problems with concentration; 6. Sleep problems
Dissociative sx – 1. Depersonalization (detached / outside of self); 2. Derealization (world distorted or dreamlike)
In peds there may be repetitive play of trauma

ADHD
DIFFERENTIAL IRRITABILITY/ANGER

ODD Oppositional defiant
disorder
Intermittent Yes
Temper tantrums & verbal
arguments. Angry, irritable
mood (emotional dysregulation)
At least 4 sx c at least 1 person
- Often loses temper
- Touchy or easily annoyed
- Angry and resentful
- Argues c authority figures
- Defies requests/rules
- Deliberately annoys
- Blames others for mistakes
- Spiteful/vindictive x2 in 6 mo
CD Conduct disorder
Yes
Proactive and predatory -
Deliberate violation of social
norms and rights of others NOT
include emotional
dysregulation
Repetitive:
- Aggression to people and
animals (bullies, weapon)
- Destruction of property (fire)
- Deceitfulness or theft (cons)
- Serious violations of rules (run
away, truant)
DMDD Disruptive mood
dysregulation disorder
No
Severe, consistent, verbal &
physical aggression. Persistent
negative mood state angry /
irritable – seen by others
IED Intermittent explosive
disorder
Yes
Impulsive Recurrent outbursts
out of proportion to situation
- Verbal aggression
OR
- Behavior (destruction property
/ aggression towards people or
animals).
 Causes problems in
relationships OR financial/legal
problems

Differential > Age 5 at least 1 x per wk x 6 CD < 18 / Antisocial PD > 18 Onset before age 10 (never < 6 > 6 yrs
mo or > 18)
DSM-5 462 (219) 469 (221) 156 (93) 466 (221)
NO c DMDD Cannot meet criteria for NO c ODD, IED, bipolar YES c ADHD / CD / ODD / ASD
Mild-1 setting / Mod–2 settings antisocial personality disorder Yes c ADHD, CD, SUD NO c DMSD
/ severe– 3settings YES c ODD 3+ x per wk Verbal - Average 2x wk x 3 mo
NO aggression, theft, deceit, or 3+ criteria past 12 mo and Present x 12 mo Aggression – past 12 mo
deliberate destruction property 1+ criteria past 6 mo No more than 3 mo without sx
Occurs in 2-3 settings Valproic acid (Depakote)
OTHER DIFFERENTIAL
- Adjustment disorder – time limited during stress. DSM-5 p. 286 (151)  Borderline PD DSM-5 p. 659 (325)
- ADHD – Can be dx c ODD/CD too. If behaviors only occur where failure to conform requires increased attention  GAD – Duloxetine (not FDA) p. 222
or sitting still (Not ODD) Not CD if hyperactive behavior does not violate rights of others. DSM-5 p. 59 (31) (122)
- Autism spectrum disorder Atypicals - Risperidone and aripiprazole FDA-approved (ages 6-17). DSM-5 p. 50 (27)  Mania / Hypomania DSM-5 p. 124
- Depression DSM-5 p. 160 (94) Can cause irritable mood in peds (65)
- Reactive attachment disorder - Persistent social and emotional disturbance characterized by at least two of the  PTSD DSM-5 p. 271 (143)
following: Minimal social and emotional responsiveness to others  Limited positive affect  Episodes of
unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with
adult caregivers. DSM-5 p. 265 (141)
PSYCHOSIS

Criterion A - 2 or more (must include 1, 2, or 3) 1. Delusions; 2. Hallucinations; 3. Disorganized speech; 4. Disorganized behavior (or catatonic); 5.
Negative ( emotional expression / avolition / anhedonia / affective flat)
If hx autism or childhood dx communication dx – mst have prominent delusions/halucinations

BRIEF PSYCHOTIC SCHIZOPHRENIFORM SCHIZOPHRENIA DSM-5 p. 99 (50) SCHIZOAFFECTIVE DSM-5 p. 105

DSM-5 p. 94 (47) DSM -5 p. 96 (49) (53)
Same as schizophrenia + for social / occupational dysfunction Features of both schizophrenia
and mood disorder (bipolar or
- Not better explained by depression, bipolar… Types (not DSM): depressive).
- Social / occupational dysfunction not required - Paranoid delusions persecution /grandeur; hallucinations – single
theme; no change in associations or affect. Intelligence unchanged Delusions / hallucinations for 2+
- Disorganized (starts before 25) weeks without mood disorder sx
Disinhibited & chaotic; ++ loose assoc; ++ flat affect; grinning / (in hx of disorder)
grimacing
- Catatonic Rigidity, waxy flexibility, excitement, speech disturbances For depression must be pervasive
- Undifferentiated ++ hallucinations & delusions; doesn’t meet other depressed mood (not just 
criteria interest or pleasure)
Residual Primary neg sx (lacks #1-4)

- Lasts 1 d to 1 mo - Lasts 1 mo to < 6 mo - Lasts > 6 mo with 1 mo of Criterion A sx

- Returns to baseline (unless tx)
within 1 mo - Returns to baseline
within 6 mo

DELUSIONAL
Criterion A – delusions 1+ mo Criterion B - Have not met Criterion A for schizophrenia Criterion C – Functioning not impaired x for impact of
delusions. Behavior not bizarre Criterion D – little relationship to mood disorder
Types: Erotomanic (love); Grandiose: Jealous (lover unfaithful); Persecutory; Somatic; Mixed; Unspecified / Bizarre content - implausible
How did you find your way to me and how can I help you?
Peds

Confidentiality
- TEEN What we talk about is confidential, I won’t tell your parents or anyone else. The exception would be if I am
worried that you are doing something that is dangerous to yourself or others. Then I’d have to tell your parents
but I won’t do that without telling you first – if at all possible I won’t talk about you unless you are in the room
- YOUNGER KID What we talk about in here’s only for us. Once in a while I may want your mom and dad to come
into the room with you so we can all talk together, but unless you’re there I won’t talk about what we do in this
room. When your mom has worries about you, I want her to tell me when your present so you can hear them
too
- PARENT Whatever I learn in our sessions I will keep confidential unless I am worried about your child’s safety or
well-being. That I will ask you to join us and we can discuss what worries me. Similarly, I will keep to myself what
you told me in confidence about yourself or your family

Lies
If I ask you something you don’t want answer, it’s okay to tell me – “I don’t want to talk about that” instead of “I don’t
know”

Questions
If you could have three wished what would they be?
What animal would you be?
if you could be any animal, what animal would you be, and what would be good about being that animal?

Friends
What are your friends names? What do you like to do with them?

Substance use
When you’re hanging out with your friends what are they drinking?

 
 

  
  
  
DEPRESSION In the past 2 week have you…
a) Hade less pleasure or interest in doing things OR b) Feeling down, depressed or hopeless?
- Are you depressed?
- How long have you been feeling this way? - Is it everyday?
- How much of the day does it last?
- When was the last time you remember not feeling depressed? / When was the last time
you went 2 months without symptoms of depression?

1+/2 x 2 wks  Timing relate to menses?  Timing relate to season?

 Feeling down, depressed most of the day  Loss of interest or pleasure almost all
everyday activities

4+/9 x 2 weeks
 Sleep  Energy  Psychomotor
 Interest  Concentration  Suicidality
 Guilt / Hopeless  Appetite
DEPRESSION – Sometimes when people get depressed their mind plays tricks on them and
they can hear things other people can’t. Has this happened to you?

PERSISTENT DEPRESSION
At least 2 years Depressed mood most of the day more days than not
+2 other sx x 2 yrs

 Appetite  Hopelessness  Worthlessness

 Concentration  Energy  Sleep

BIPOLAR Has there been a period of time that felt the opposite of depressed – for a week or
so you felt like you were on an adrenalin high and could conquer the world? Or so irritable
you are picking fights or snapping at people
Sleeping less than usual but still have a lot of energy?
Starting more projects or activities than normal or doing more risky things?

 I – Mania / Hypomania  II – Hypomania and depression (5+ sx)

3+ sx (4+ if mood only irritable) x 1+ weeks – mania / 4+ days hypomania

 Distractibility  Flight of ideas (racing thoughts)  Talkativeness
 Indiscretion  Activity increase
 Grandiosity  Sleep deficit
ANXIETY >6 mo
GAD – fear future events – multiple worries
Agoraphobia – fear inability of escape
Specific phobia
Social anxiety disorder – fear of possible scrutiny by other
ANXIETY – has your anxiety ever caused your imagination to take over so you hear voices or
think people are trying to harm you?

GAD Are you a worrier? / what do you worry about?

Anxiety and worry more days than not – multiple settings/activities 3+/6 x 6 mo (1 sx peds)

 Muscle tension  Concentration  Irritability

 Fatigue  Restlessness (on edge)  Sleep

PANIC DISORDER Have you ever had a panic /anxiety attack?

Sudden rush of fear / nervousness heart pounds, short of breath, afraid you are going to die

Abrupt, unexpected surge fear – recurrent / quickly peaks 4+ sx

 Short of breath  Dizzy / light head  Trembling / Shaking
 Choking  Fear losing control  Sweating
 Palpitations  Fear dying  Chills / heat
 Chest pain  Paresthesia (numbness / tingling)
 Nausea / abd pain  Derealization / Depersonalization (detached)
At least one attacks followed by 1+ / 1 mo
 Worry or concern about another attack or consequences losing control / going crazy
 Changes in behavior to avoid having another attack

SOCIAL ANXIETY Are you uncomfortable in social situations? >6 mo

What is it about those situations that makes you uncomfortable? Watched
 Fear of social situations where exposed to possible scrutiny or being observed
 Afraid of negative evaluation – embarrassing leading to rejection
 Situation provokes fear/anxiety  Avoids situations

AGORPHOBIA Any situations or setting that make you nervous?

Fear of inability to escape +2/5 x >6 mo
 Cause fear and are avoided  Open spaces  In line/crowd
 Public transportation  Enclosed spaces  Outside home

SPECIFIC PHOBIA Any special fears such as insects or flying? >6 mo

Provokes immediate fear or anxiety
OCD Obsessive-Compulsive Disorder Do you have symptoms of OCD?
- Unpleasant thoughts, urges or images that repeatedly enter your mind? (Obsessions)
- Feeling driven to perform certain behaviors or mental acts over and over again? (Compul)
Obsessions – unwanted thoughts, images, or urges that can be distressing such as thinking
about killing someone you love – or the house is unlocked and will be robbed – you are
contaminated by germs or saving every scrap of paper with fear you will need it later?
Compulsions such as needing to do something over and over again like washing your hands, or
checking the stove is off? straightening / mental rituals – counting / checking / hoarding
 Obsessions – suppress thoughts/impulses - neutralize through compulsions
 Compulsions – rigid rules to reduce distress
 Time - >1 hr / clinically significant  Insight

PTSD Posttraumatic Stress Disorder Do you have PTSD, which means having memories or
dreams of a terrible experience, like being attacked or surviving a natural disaster?
> 1 mo / if < 1 mo - acute stress  Derealization  Depersonalization (outside body)

Re-experience 1+/5  Dreams  Psych distress to cues symbolize/resemble

 Memories  Flashbacks  Physical distress to cues

Avoidance 1+/2  Memories/thoughts  Reminders – places/objects/people

Cognition or mood 2+/7  Less interest  Negative emotions

 Amnesia  detachment  Lack of positive emotions
 Blame self / others  Neg view others / self / world “ruined forever”

Arousal / reactivity 2+/6

 Irritable / Angry  Reckless / self-destructive  Concentration
 Hypervigilance  Exaggerated startle  Sleep
ADHD When you were young did you have problems with paying attention in school or
“do you remember needing any extra help while in school with your speech or learning?”
hyperactivity Some sx present before 12 / several settings
Inattention 6+ (kids) 5+ (adults) >6 mo
Organization  Can’t organize tasks
 Problems finishing tasks  Loses things
Attention
 Poor focus  Easily distracted  Doesn’t listen spoken to directly
 Forgets easily  Careless mistakes  Avoids tasks requiring concentration

Hyperactivity 6+ (kids) 5+ (adults) >6 mo

Impulsivity  Can’t play quietly  Problems waiting for turn
 Talks too much  Blurts out answers  Interrupts others
Movement excess  Fidgets / squirms  Leaves seat
 Active when inappropriate (adult-restless)  Driven by a motor

SCHIZOPHRENIA SPECTRUM
- Have you had any experiences feeling like your dreaming when you’re awake?
- Any strange or odd experiences lately you can’t explain?
- Do you ever hear, see, smell or see things other people can’t
- Do you ever feel like people are bothering or trying to harm you?
- Does it seem like strangers look at you a lot or make comments about you?
Sometimes when people get ____ their mind plays tricks on them and they can hear things
other people can’t. Has this happened to you?
- Do you think your mind has been playing tricks?
Brief psychotic 1d-1mo Schizophreniform 1 -6 mo Schizophrenia > 6 mo

Hallucinations – I want to understand what the ___ are like for you
– If they could be recorded, what would I hear?
 Male/female  How many?  Anyone you know
 Telling you to do anything?  Tell you to hurt yourself or someone else?
 Happen certain time of day  Talking directly to you or someone else

Negative sx
 Avolition – sit for long periods  Asociality – lack of social interest
 Ahedonia – decreased pleasure  Alogia – less talkative

Delusions - Follow up question – how do you know? / what is it that makes you sure of that?
/ what makes you know that?/ what’s that like?
SOMATIC DISORDERS – Do you worry a lot about your health?

Somatic Symptom Disorder – usually >6 mo

 Sx such as pain / fatigue – May or may not have medical dx
 Excessive thoughts of seriousness  High anxiety re sx
 Excessive time/energy focused on thinking about/responding to sx
Illness Anxiety Disorder – Do you ever feel like your illnesses are not being taken seriously?
Preoccupation with having a serious illness present >6 mo
 Fears serious disease - no or few sx present
 Excessive checks or avoids care due to fear  High anxiety about health

EATING DISORDERS – Have you ever thought you might have an eating disorder such as
bulimia or anorexia? Have you ever been concerned you were overweight?
Anorexia – Weight Fear Bothers Anorexics
Have you ever weighed less than people thought you should? Lowest weight?
 Low Weight  Fear weight gain  Distorted Body image
Bulimia – average 1x/wk for 3 mo
Have you ever felt you’re eating was out of control? Eat a lot and can’t stop? How often?
 Binge eating (large amnt) and/or  Eating feels out of control
 Purging behaviors  Distorted body image
Binge Eating– average 1x/wk for 3 mo – No purging How often?
 Binge eating (large amnt) and/or  Eating feels out of control
 Rapid eating  Uncomfortably full
 Not physically hungry  Disgusted, depressed, guilty
 Eats alone because of being embarrassed at amount of food eaten

IMPULSE CONTROL
Oppositional Defiant Disorder if <5 yrs almost daily if > 5 yrs at least 1x per week
Angry / Irritable > 4 from any category for 6 mo
 Loses temper  Touchy/easily annoyed  Angry/resentful
Argumentative/Defiant
 Argues with authority figures  Deliberately annoys
 Defies requests from authority figures  Blames others mistakes/behaviors
Vindictiveness  Spiteful / vindictive at least twice in 6 mo

Conduct Disorder 3+/15 in 12 mo with at least 1+ past 6 mo

Aggression to people/animals
 Cruel 1 people/2 animals  Has used a weapon  Stolen while confronting
 Bullies or threatens  Forced sex  Initiates physical fights
Destruction of property Has deliberately…
 Set fire –planning intentional damage  Destroyed property (not incl. fire)
Deceitfulness / theft
 Broken into house, car…  Cons others for favors/goods
 Stolen higher value item without confrontation (shoplifting / forgery)
Violation of rules
 Stayed out all night < age13  Truant from school < age 13
 Run away (2x – short period or 1x – longer period)

Intermittent Explosive Disorder – Behavioral outbursts out of proportion > 6 yrs old
 Verbal aggression / non-damaging physical aggression 2x/wk for 3 mo OR
 Physical aggression with injury/damage x3 within 12 mo

SUBSTANCE USE DISORDER 2+/11 in 12 mo period

 Larger amounts/more than intended  Desire to cut down or control use
 Failure to meet role at home/work   time obtaining / recovering
 Recurrent / persistent social problems  Known physical/psych problem
 Gives up social/recreational activities  1
Craving / 2 Tolerance
 Use in situations physically hazardous  Withdrawal
Do you have an occasional drink? 12-oz beer/wine, 1-oz shot of hard liquor
On the days you drink, how many drinks do you usually have
C – have you ever felt you should, or tried to cut down your drinking? (Why)
A – do you ever get annoyed by people getting on you for your drinking?
G – Ever felt guilty about your drinking?
E – ever take a drink first thing to get rid of hangover / steady your nerves?
Do you think you have a drinking problem?

What types of recreational drugs do you use – like marijuana / LSD / cocaine / opioids
How often? (marijuana / cocaine / speed / heroin)
- Do you ever use prescription medications not prescribed for you or differently than they have been
prescribed
-Any problems with gambling
SUBSTANCE – has ____ ever cause your mind to play tricks on you so you hear voices or think people are
trying to harm you?
My name is Lori Hart I’m a psychiatric mental health nurse practitioner student
at University of Kansas. What would you like me to call you?
Let me confirm a couple of things with you
 where are you today? Who is there with you?
 If we were to lose connection what would be the best telephone number
to reach you?
Have you received the information sheet that tells you what to do if we have any
technical issues? Any problems in the past with these types of visits?

I’m calling today from Cheyenne WY – I am working from an office at home. My

instructor, Dr. Whitney is also in this virtual room with us to give me feedback on
my performance. No one else can hear or see you so the information you are
sharing is confidential with a couple of exceptions – if it seems you are going to
hurt yourself, hurt someone else or you tell me about possible danger to a child
or elder.

We’ve got about 30 minutes together today. I will stop to check in with you
every few minutes but feel free to stop me at any point if you can’t hear or see
me
Everything look and sound clear?
Does that all sound like what you expected?

Any questions or concerns before we get started?

The last appointment I see was ____ is that right? At that time _____

At that time you were also seeing ____ for therapy

What’s happened since then?

Describe your mood 0-10/ anxiety 0-10/ Sleep / energy / stressors / appetite /
pain 0-10 / substances

Review meds
How many days per week taking medication?

Side effects?

ROS Any new medical issues. Or labs?

1. Constitutional fever / illness
2. Eyes
3. Ears/Nose/Mouth/Throat
4. Cardiovascular chest pain/palpitations
5. Respiratory SOB
6. Gastrointestinal N/V, constipation, diarrhea
7. Genitourinary. Problems with sexual function
8. Musculoskeletal
9. Integumentary Rash
10. Neurological HA / dizziness / weakness / sedation / movement face-
extremities / seizure
11. Endocrine
12. Hemotologic/Lymphatic
13. Allergies/Immune
I’m showing you are allergic to _____ anything new

Before we jump into the issues that brought you here today – I’d like to know a bit about you
as a person.
How would you describe yourself? What do you like best about yourself? Not like so much?

Anything about your cultural or beliefs I should know?

How can I be of help today?
 What is going on that led _____ to think you might benefit from coming in today
 Nothing may be wrong but since you are here, let’s figure if there is something I might be able to help
you with
 What would make this a helpful visit?

HPI
What has been different over the last few weeks that led you to see me today?

Onset
When do you last remember feeling perfectly well?
When do you think this started? Any events that made things worse?

- Symptoms DURATION How long have you… PERSISTENCE feel like that nearly every day?

What is one word to describe your mood in the last week?

How would a friend who knows you describe your recent mood?
How have you been sleeping? (what time go to bed / wake up / feel rested /
energy despite not sleeping?
Nightmares?
Appetite? Weight loss or gain? Does food taste good to you?
Energy level? Is this a change?
Interest in activities? Getting less pleasure in activities that used to be fun?
Changes in your memory? Concentration?
How have these sx affected your work, homelife, or things you like to do?
How were things before you started having these sx?

If you could wake up with all of your symptoms gone how would your day be different?

PSYCH HX
What sort of treatment have you had for your _____?
What was most helpful?
Have you ever been hospitalized for _____?
First hospitalization? How many total? Past year? Last?
What medications have you tried?
Counseling or therapy? (cognitive / behavioral / psychodynamic?)
What sort of things did you focus on? What was or was not helpful?

Have you had treatment for any other mental health issues?
Any history of suicide attempts
MED HX
- How is your general health?
- What medications do you currently take? Any other over the counter, vitamins, or herbal
products? Contraception?
- Who do you see for your medical care? Last time you saw them
- Any history of
Diabetes
Thyroid disorder?
Heart issues – like high blood pressure
Problems with your lungs like asthma
Head injuries / headaches/ seizures / strokes
- Any allergies/reactions to medications?
- Surgeries?
- Preg / birth control / breastfeeding?

FAMILY HX
Thinking about your blood relatives – like siblings – uncle - grandparents
- What medical or neurological problems have they had?
- What mental health problems? (depression /bipolar disorder / anxiety / psychosis / drug or
alcohol abuse / suicide attempts / hospitalizations)

SOCIAL HX I’d like to ask you some questions about your childhood and current life
How old are you?
During your mom’s pregnancy and delivery any problems
Did you walk / talk on time? Any health issues during childhood
Childhood
- What was your growing up and childhood like? (birthplace / siblings /close family / losses
from death or divorce?)
- Did you ever feel mistreated as a child? / was growing up a safe time in your life?
- What was school like for you? (friends / discipline problems / school activities )
Any problems with paying attention in school or hyperactivity?
-How far did you go in school – any special work training?
Adult
How do you support yourself? Tell me about your work history (number and type of jobs, job
satisfaction / longest you’ve worked at one job)
any periods of unemployment?
Money a problem?
- Military service? When / how long / combat / disciplinary problems / exposure noise
chemicals
-Where are you living? Who lives with you?
Have you moved much
 What’s the longest you’ve lived in one place?
Ever been homeless?
- Do you have people in your life you can trust and depend on?
-Tell me about your friends (number / how long do you keep friends)
- Tell me about your current and past relationships
Are you in a committed relationship or have a partner?
Past marriages / divorce
What are the good parts about this relationship / difficult parts
Are you satisfied with your sex life
-Any children?
- What social networks do you have like church, clubs, sports teams?
- Any spiritual beliefs that would be helpful for me to know about?
- What legal issues have you had? Ever been arrested? Circumstances? Outcome?
-Anything else about your current life situation I haven’t asked about?

SUBSTANCE USE
How much caffeine do you use on average coffee / tea / energy drink / tablets
Have you ever smoked?
Do you have an occasional drink? 12-oz beer/wine, 1-oz shot of hard liquor
On the days you drink, how many drinks do you usually have
C – have you ever felt you should, or tried to cut down your drinking? (Why)
A – do you ever get annoyed by people getting on you for your drinking?
G – Ever felt guilty about your drinking?
E – ever take a drink first thing to get rid of hangover / steady your nerves?
Do you think you have a drinking problem?
Medical. Liver trouble, vomiting spells, blackouts (amnesia for events while drinking)
Legal. Arrests, drunk driving, accidents
Interpersonal. Loss of friends, divorce, fighting, guilt feelings
Financial. Spending money on drink/drugs that should have gone to food or family support
Job. Absenteeism, being fired

“Were you ever treated for the use of [alcohol, drugs]?” “What happened as a result of treatment?”
“What’s your longest period of [sobriety, being clean]?” “How did you achieve it?”

What types of recreational drugs do you use – like marijuana / LSD / cocaine / opioids
How often? (marijuana / cocaine / speed / heroin)
- Do you ever use prescription medications not prescribed for you or differently than they
have been prescribed
-Any problems with gambling
SUBSTANCE – has ____ ever cause your mind to play tricks on you so you hear voices or think
people are trying to harm you?
ROS
SUICIDE / HOMICIDE
MSE

CLOSING
Do you have any questions or concerns I have not asked you about?

Sounds like you might have…

I’m going to ask you about some common medical problems in the past or currently
- General: weight loss, fever, chills, weakness / history of cancer / infections such as HIV or TB, breast
discharge or lumps
- Endocrinologic: Thyroid problems - excessive sweating, intolerance to heat or cold. Diabetes - No
polydipsia or polyphagia.
- Skin: Itching or rashes / open or slow healing sores / eczema or psoriasis / problem moles
- HEENT: Vision or hearing problems (double vision) / smelling, taste or throat problems (such as hoarseness
/ trouble swallowing)/ frequent nasal congestion / see things or hear things other people don’t / teeth
- CV/Resp: heart problems - Chest pain/pressure / palpitations or high blood pressure / High cholesterol /
Bleeding, easy bruising or anemia / Lung problems – asthma, SOB, cough
- GI: Stomach problems such as pain, N/V, constipation/diarrhea, heartburn / Changes in stool / Ever make
yourself vomit
- GU (women): Problems with urination (burning, pain, frequency, sudden loss of urine), problems with
sexual drive – pain with intercourse, STI (HIV, syphilis), last pap smear and mammogram, periods regular –
LRMP contraception Any chance or pregnancy/BF Y/N
- GU (men): Problems with urination (burning, pain, frequency, sudden loss of urine), problems with sexual
functioning or drive, STI (HIV, syphilis), swelling or lumps in testicles
- Neurological: Headaches / head injuries / dizziness / seizures / LOC / loss of feeling / stroke
- Musculoskeletal: Muscle pain or stiffness. Joint pain or stiffness. Falls.
ROS
Screening Questions
Depression Are you depressed? (sad, blue, down)
In the past 2 week have you…
a) Hade less pleasure or interest in doing things OR b) Feeling down, depressed or hopeless?
Bipolar Has there been a period of time that felt the opposite of depressed – for a week or
more you felt like you were on an adrenalin high and could conquer the world? Or so
irritable you are picking fights or snapping at people? Did people tell you you were talking
faster than normal or acting unusual? What was your sleep like during this period?
Sleeping less than usual but still have a lot of energy?
Starting more projects or activities than normal or doing more risky things?
Anxiety Are you a worrier? What do you worry about?
Have you ever had a panic /anxiety attack?
Any situations or setting that make you nervous – like social situations? Any special fears
such as insects or flying? PTSD – painful memories or dreams of a bad experience
OCD Do you have symptoms of OCD?
- Unpleasant thoughts, urges or images that repeatedly enter your mind? – like having to
wash your hands repletely or count things.
- How clean do you have to have your house? Things lined up in certain way?
ADHD Problems with paying attention. Lots of fidgeting? Are you distractible (paying
attention to the person next to you rather than teacher? / looking out window?). Hard time
finishing things? If you were sent to your room to get your shoes, get interested in something
else and forget about shoes? Class clown? Being impulsive - do things without thinking about
consequences? Lose your temper easily? If you have money are you able to save – or do you
spend?
Eating Disorder Have you ever been concerned you were overweight? Have you ever
thought you might have an eating disorder such as bulimia or anorexia?
Somatic Disorder Do you worry a lot about your health? Any unexplained aches or pains?
Do you ever feel like your illnesses aren’t being taken seriously enough?
Schizophrenia Any halucinations?
- Do you ever hear, see, smell or see things other people can’t
- Do you ever feel like people are bothering or trying to harm you?
- Does it seem like strangers look at you a lot or make comments about you?
- Experiences feeling like your dreaming when you’re awake?
- Any strange or odd experiences lately you can’t explain?
Sometimes when people get ____ their mind plays tricks on them and they can hear things
other people can’t. Has this happened to you?
Dementia Any problems with your memory (such as learning new information) or locations
such as getting lost in places you’ve been before?
PD
BPD (idealize than devalue / when people reject me I fall apart, hate them, and get
suicidal) – Have people often disappointed you? When something has gone
wrong in your life have you done something to hurt yourself like cutting or
overdosing? Is it hard when you feel like people don’t want you in their lives? Do
your relationships with friends and lovers tend to be intense and have a lot of
ups and downs?
Cluster A - odd
Paranoid (guarded & suspicious / Others take advantage of me) – Do you believe
most people can’t be trusted? Have people turned against you for no good
reason?
Schizoid (shy, aloof, preoccupied / I like to be alone / my world is empty)– Do you
prefer to be alone? What things do you really enjoy doing?
Schizotypal (odd / I want friends but people find me strange) – Are you pretty
uncomfortable around other people? Do you have ideas that others don’t
understand or find unusual?
Cluster B – Dramatic
Antisocial (cocky, arrogant, victim / I take advantage of others and don’t feel bad
about it) – Do you like getting away with things when you can? Have you ever
done anything that might have gotten you in trouble with the law?
Histrionic (dramatic and self-revealing / I’m sexy, charming, and need to be the
center of attention) – Do you like to be the center of attention? When you have
an emotion do you keep it inside or express it?
Narcissistic (Haughty & lots of complaints of past treatment / I’m special and
talented and get frustrated when others don’t see it) – Do you get frustrated when
others don’t meet your standards? What are your ambitions?
Cluster C – Anxious
Avoidant (shy, nervous, but eager to open up / I afraid what others will think) – Do
you avoid meeting or getting close to people? Is this because you like being
alone or you don’t want to be rejected?
Dependent (immediate want affection / I need others for direction and want to
please) – Are you pretty independent or do you like to have others help you
when possible? Who makes most of your decisions?
Obsessive-Compulsive (Meticulous – give lots of accurate details / driven, lists,
serious about life) – Are you a perfectionist? Do you work so hard there is no time
for fun?
Suicide / HI
VHA Pocket Card Suicide Risk Questions
Are you feeling hopeless about the present or future?
Have you had thoughts of taking your life?
When did you have these thoughts?
Do you have a plan to take your life?
Have you ever had a suicide attempt? Description\Dates:
- How do you see your future? Do you think things can get better or is it pretty
hopeless?
-Sometimes when people feel as ____ as you’ve described, it feels like life is not
worth living. Have you ever felt that way?
-Have you thought about suicide? Do you wish you were dead or just want the
pain to stop
-What ways have you thought about using? (hanging / gun / pills / jumping /
using gas)
How close have you come? Now
Planned it out in your mind - Are you feeling suicidal now
Have what you need - Any specific plans to hurt yourself
Pills in hand / gun loaded - If you were feeling suicidal could
you
Suicide note / affairs in order promise to call Someone?
What stopped you

Any thoughts about hurting someone else?

DV / SAFETY
Because violence at home has become such a common problem we ask all clients
about it. Safe/secure?

1. Are you in a situation where anyone is calling you names, or has threatened you
in ways that make you feel uncomfortable or afraid?
2. Have you been hit, kicked, pushed, strangled, threatened, or otherwise hurt by
a family member, caretaker, or your current or former partner?
3. Has your partner forced you to have sexual activities
4. Do you feel unsafe returning home?
Are you a worrier? Ever had a panic attack? Worry about what others think / / trouble controlling anxiety /
OCD – count things – how clean is room / wash hands all the time / see things others don’t
Feel sad sometimes / impulsive – do things without thinking about it – How are you with money? Save or
spend / sleep disturbances or easily startled
HA/Stomaches
Oppositional behavior – like to argue
1. Depression – are you depressed? (sad, blue, down)
2. Bipolar – sleeping less than usual, but still have lots of energy? Starting more projects than usual or doing
more risky things? Ever had a consistent week or so when you were sleeping less when you felt happy and
energetic or snappy and irritable and your friends told you you were talking too fast or acting different?
3. Anxiety – are you a worrier? What do you worry about? Ever had a panic attack? Uncomfortable in social
situations? Avoid anything because of fears? PTSD (painful memories
4. Schizophrenia 5. OCD 6. PTSD 7. ADHD 8. Impulse control 9. Dementia 10. Eating disorder 11.
Somatic
Why do you ask?
You’re right there is no way I can truly understand what it is like for you, but I’d like to try.
Can you tell me more about
Anyone who’s had your problem would feel
When you mentioned ____ you looked a bit____ - what were you feeling?
What’s on your mind as you’re crying?

I’d like to change gears, now, and ask you about…

I’d like to hear about that later, if there’s time. Now, let’s focus on…
Let me interrupt here to pursue something else that’s important.

For each positive question ask re

- DURATION How long have you… and
- PERSISTENCE Do you feel like that nearly every day?
What impact does it have on your life