OPD- Psychiatric Assessment Sheet ‫مجمع إرادة للصحة النفسية بالرياض‬

‫إدارة الخدمات الطبية‬

<DOC_STATUS>
Date: Treating Psychiatrist :
Patient Name File No Age Sex Nationality
<PATIENT_NAME> <FILE_ID> <AGE> <SEX> <NAT>
Occupation Source of Referral

Source of information and reliability <SOURCE_OF_INFORMATION>

Main Complaints
<MAIN_COMPLAINTS>
History of present illness
<HISTORY_OF_PRESENT_ILLNESS>

Family History
<FAMILY_HISTORY>
Personal History
Early development <EARLY_DEVELOPMENT>

Childhood <CHILDHOOD>

School <SCHOOL>

Occupations <OCCUPATIONS>

Adolescence <ADOLESCENCE>

Sexual History <SEXUAL_HISTORY>

Marital History <MARITAL_HISTORY>

Medical and Surgical History ( in Females, including Menstrual History)

<MEDICAL_AND_SURGICAL_HISTORY>

Past Psychiatric History

<Past_Psychiatric_History>
History of substances, alcohol and smoking <HISTORY_OF_SUBSTANCES_ALCOHOL_AND_SMOKING>

Criminal History <CRIMINAL_HISTORY>

Premorbid Personality

Form No. ( M. – 001) Issue No. (02) Page No. 1 -

 OPD- Psychiatric Assessment Sheet ‫مجمع إرادة للصحة النفسية بالرياض‬
‫إدارة الخدمات الطبية‬

Attitudes to others, social, Family <ATTITUDES TO_OTHERS_SOCIAL_FAMILY>

Attitudes to self <ATTITUDES_TO_SELF>
Moral and religious attitudes <MORAL_AND_RELIGIOUS_ATTITUDES>

Prevailing Mood <PREVAILING_MOOD>

Leisure activities and interest <LEISURE_ACTIVITIES_AND_INTEREST>
Fantasy life <FANTASY_LIFE>
Reaction to stress <REACTION_TO_STRESS>
Mental state examination
Appearance and general behavior <APPEARANCE_AND_GENERAL_BEHAVIOR>
Talk <TALK>
Mood <MOOD>
Thought <THOUGHT>
Perception <PERCEPTION>

Cognitive state
Orientation <ORIENTATION>
Attention and concentration (What test applied?) <ATTENTION_AND_CONCENTRATION>
Memory
 Immediate <IMMEDIATE>
 Recent <RECENT>
 Remote<REMOTE>
Intelligence (e.g. Math. Calculation) <INTELLIGENCE>
Abstract thought (similarities & differences, proverb interpretation) <ABSTRACT_THOUGHT>
Judgment <JUDGMENT>

Insights
 To the mental illness <TO_THE_MENTAL_ILLNESS>

 To the treatment <TO_THE_TREATMENT>

Form No. ( M. – 001) Issue No. (02) Page No. 2 -

 OPD- Psychiatric Assessment Sheet ‫مجمع إرادة للصحة النفسية بالرياض‬
‫إدارة الخدمات الطبية‬

Formulation <FORMULATION>

Differential diagnosis
Axis I : <AXIS_I>
Axis II : <AXIS_II>
Axis III : <AXIS_III>
Axis IV : <AXIS_IV>
Axis V : <AXIS_V>

Investigations <INVESTIGATIONS>

Treatment plan ( in Biopsychosocial Approach) <TREATMENT_PLAN>

Doctor Name : ………………………………………………….. Date : ………………...………………….

Form No. ( M. – 001) Issue No. (02) Page No. 3 -