Interview

Student completing form:

SECTION I/SUBJECTIVE

Identifying Data:

Source & Reliability:

Chief Complaint:

History of Present Illness (Bold symptoms that meet the DSM-5-TR Diagnostic Criteria)

.

Psychiatric Review of Systems: (address any area not covered in HPI, all positive findings must be addressed in HPI)

Mood:

A. Depression:

B. Mania:

Anxiety:

A. Generalized:

B. Panic:

C. OCD:

D. PTSD:

Psychosis:

A. Hallucinations:

B. Paranoia:

C. Delusions:

D. Perception:

Other:

A. ADHD:

B. Eating Disorder:

Psychiatric History:

Previously Tried Medications:

Previous Hospitalizations for Mental Health:

Previous Counseling/

Therapy:

Previous Suicide Attempts:

Previous Non-Suicidal Self-Harm Behaviors:

Substance Use/Abuse:

Nicotine:

Supplements:

Caffeine:

Alcohol:

Marijuana:

Illicit Drug Use:

Misuse of Prescription Medications:

Medical History:

Illness/Injuries:

Last Medical Exam:

Current Medications:

(prescriptions, over-the-counter, and supplements)

Allergies:

Previous Surgeries:

Last Menstrual Period:

Contraception:

Family Psychiatric or Medical History:

Developmental/

Social History:

Adverse Life Events:

Grew up with:

Developmental History: delivery issues/

Milestones, etc:

Education History & Education Level:

Work History:

Relationship Status:

Children:

Current Living Situation:

Medical Review of Systems (as appropriate for the client’s medical history):

Constitutional:

HEENT:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Skin:

Neurological:

Musculoskeletal:

Section 2/Objective

Vital Signs:

Mental Status Exam:

Appearance:

Orientation:

Concentration:

Manner:

Speech:

Mood:

Affect:

Thought Process:

Thought Content:

Perceptions:

Memory and Cognition:

Judgment:

Insight:

Physical Exam: (Musculoskeletal, skin, neuro - if indicated)

NA (this is a telehealth visit)

Formulation/

Diagnosis:

Provide the complete diagnostic criteria for the diagnosis. Next to each criterion document in bold if the patient met or unmet the criteria.

Diagnosis:

Diagnostic Criteria:

Differential Diagnosis:

Psychiatric Mental Health Differential Diagnosis:

Medical Differential Diagnosis:

Suicide Risk Assessment:

Suicidal thoughts (passive/active):

Plan:

Intent:

Risk Factors:

Protective Factors:

Risk Level:

Risk to Others:

Reflection/Self-Assessment

Discuss what went well during the visit:

If you could go back and change something, what would it be?

Identify items forgotten. Did you forget to ask about something? If so, what?