BIOPSYCHOSOCIAL HISTORY

PRESENTING PROBLEMS

Presenting problems                                                  Duration (months)                                                      Additional information:

                                                                                                                                                                       

                                                                                                                                                                       

                                                                                                                                                                       

 

 

CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)

None = This symptom not present at this time  ¥  Mild = Impacts quality of life, but no significant impairment of day-to-day functioning

Moderate = Significant impact on quality of life and/or day-to-day functioning  ¥  Severe = Profound impact on quality of life and/or day-to-day functioning

 

                                       None     Mild        Moderate      Severe                                         None     Mild        Moderate    Severe                                                None     Mild   Moderate  Severe

depressed mood              [  ]       [  ]          [  ]              [  ]          bingeing/purging         [  ]        [  ]          [  ]            [  ]        guilt                                      [  ]       [  ]     [  ]          [  ]

appetite disturbance         [  ]       [  ]          [  ]              [  ]          laxative/diuretic abuse   [  ]        [  ]          [  ]            [  ]        elevated mood                       [  ]       [  ]     [  ]          [  ]

sleep disturbance             [  ]       [  ]          [  ]              [  ]          anorexia                       [  ]        [  ]          [  ]            [  ]        hyperactivity                         [  ]       [  ]     [  ]          [  ]

elimination disturbance   [  ]       [  ]          [  ]              [  ]          paranoid ideation          [  ]        [  ]          [  ]            [  ]        dissociative states                   [  ]       [  ]     [  ]          [  ]

fatigue/low energy          [  ]       [  ]          [  ]              [  ]          circumstantial symptoms          [  ]          [  ]            [  ]        [  ]                                         somatic complaints     [  ]     [  ]              [  ]              [  ]

psychomotor retardation            [  ]          [  ]              [  ]          [  ]                                loose associations              [  ]        [  ]                                         [  ]       [  ]     self-mutilation                  [  ]              [  ]              [  ]                                       [  ]

poor concentration          [  ]       [  ]          [  ]              [  ]          delusions                      [  ]        [  ]          [  ]            [  ]        significant weight gain/loss    [  ]       [  ]     [  ]          [  ]

poor grooming               [  ]       [  ]          [  ]              [  ]          hallucinations               [  ]        [  ]          [  ]            [  ]        concomitant medical condition          [  ]     [  ]          [  ]     [  ]

mood swings                  [  ]       [  ]          [  ]              [  ]          aggressive behaviors    [  ]        [  ]          [  ]            [  ]        emotional trauma victim        [  ]       [  ]     [  ]          [  ]

agitation                          [  ]       [  ]          [  ]              [  ]          conduct problems         [  ]        [  ]          [  ]            [  ]        physical trauma victim           [  ]       [  ]     [  ]          [  ]

emotionality                    [  ]       [  ]          [  ]              [  ]          oppositional behavior   [  ]        [  ]          [  ]            [  ]        sexual trauma victim              [  ]       [  ]     [  ]          [  ]

irritability                       [  ]       [  ]          [  ]              [  ]          sexual dysfunction       [  ]        [  ]          [  ]            [  ]        emotional trauma perpetrator            [  ]     [  ]          [  ]     [  ]

generalized anxiety          [  ]       [  ]          [  ]              [  ]          grief                             [  ]        [  ]          [  ]            [  ]        physical trauma perpetrator   [  ]       [  ]     [  ]          [  ]

panic attacks                    [  ]       [  ]          [  ]              [  ]          hopelessness                 [  ]        [  ]          [  ]            [  ]        sexual trauma perpetrator      [  ]       [  ]     [  ]          [  ]

phobias                           [  ]       [  ]          [  ]              [  ]          social isolation              [  ]        [  ]          [  ]            [  ]        substance abuse                     [  ]       [  ]     [  ]          [  ]

obsessions/compulsions  [  ]       [  ]          [  ]              [  ]          worthlessness               [  ]        [  ]          [  ]            [  ]        other (specify)                       [  ]       [  ]     [  ]          [  ]

 

 

EMOTIONAL/PSYCHIATRIC HISTORY

[  ]    [  ]     Prior outpatient psychotherapy?

No    Yes     If yes, on                occasions. Longest treatment by                             for             sessions from         /                 to             /                

                                                                                                                   Provider Name                                                 Month/Year              Month/Year

 

                     Prior provider name          City                       State         Phone                    Diagnosis            Intervention/Modality     Beneficial?

                                                                                                                                       

                                                                                                                                                                                                                                                                                 

[  ] [  ]     Has any family member had outpatient psychotherapy? If yes, who/why (list all):                                                                                           

No  Yes                                                                                                                                                                                                                                                              

[  ] [  ]     Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?

No    Yes     If yes, on                occasions. Longest treatment at                                                                   from        /                 to             /                

                                                                                                                   Name of facility                                               Month/Year              Month/Year

 

                     Inpatient facility name    City                       State         Phone                    Diagnosis            Intervention/Modality     Beneficial?

                                                                                                                                       

                                                                                                                                                                                                                                                                                 

 

[  ]  [  ]    Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes,

No  Yes who/why (list all):                                                                                                                                                                                                                                          

 

[  ]    [  ]       Prior or current psychotropic medication usage? If yes:

No    Yes     Medication                   Dosage           Frequency    Start date   End date     Physician                          Side effects             Beneficial?

                                                                                                                                                                                                                                                                                 

                                                                                                                                                                                                                                                                                 

 

[  ]    [  ]    Has any family member used psychotropic medications? If yes, who/what/why (list all):                                                                                

No    Yes                                                                                                                                                                                                                                                             

 

FAMILY HISTORY

FAMILY OF ORIGIN

 

Present during childhood:                                                  Parents' current marital status:              Describe parents:

                                  Present         Present         Not                [  ] married to each other                               Father                                           Mother

                                  entire            part of          present         [  ] separated for         years                            full name                                                                          

                                  childhood    childhood    at all             [  ] divorced for         years                              occupation                                                                       

mother                     [  ]                  [  ]                  [  ]                  [  ] mother remarried        times                    education                                                                          

father                       [  ]                  [  ]                  [  ]                  [  ] father remarried        times                       general health                                                                 

stepmother             [  ]                  [  ]                  [  ]                  [  ] mother involved with someone

stepfather               [  ]                  [  ]                  [  ]                  [  ] father involved with someone              Describe childhood family experience:

brother(s)               [  ]                  [  ]                  [  ]                  [  ] mother deceased for        years                  [  ] outstanding home environment

sister(s)                   [  ]                  [  ]                  [  ]                        age of patient at mother's death             [  ] normal home environment

other (specify)      [  ]                  [  ]                  [  ]                  [  ] father deceased for        years                     [  ] chaotic home environment

                                                                                                            age of patient at father's death                [  ] witnessed physical/verbal/sexual abuse toward others

                                                                                                                                                                                    [  ] experienced physical/verbal/sexual abuse from others

 

Age of emancipation from home:                           Circumstances:                                                                                                                                                    

                                                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                                                             

 

Special circumstances in childhood:                                                                                                                                                                                                                        

                                                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                                                             

 

IMMEDIATE FAMILY

Marital status:                                          Intimate relationship:                                        List all persons currently living in patient's household:

[  ] single, never married                          [  ] never been in a serious relationship          Name                              Age      Sex       Relationship to patient

[  ] engaged           months                         [  ] not currently in relationship                                                                                                                                           

[  ] married for           years                         [  ] currently in a serious relationship                                                                                                                                 

[  ] divorced for         years                                                                                                                                                                                                                                

[  ] separated for          years                       Relationship satisfaction:                                List children not living in same household as patient:

[  ] divorce in process          months       [  ] very satisfied with relationship                                                                                                                                     

[  ] live-in for          years                           [  ] satisfied with relationship                                                                                                                                               

[  ]          prior marriages (self)                  [  ] somewhat satisfied with relationship                                                                                                                           

[  ]          prior marriages (partner)           [  ] dissatisfied with relationship

                                                                        [  ] very dissatisfied with relationship             Frequency of visitation of above:                                                   

 

Describe any past or current significant issues in intimate relationships:                                                                                                                                                

                                                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                                                             

 

Describe any past or current significant issues in other immediate family relationships:                                                                                                 

                                                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                                                             

                                                                                                                                                                                                                                                                             

 

MEDICAL HISTORY (check all that apply for patient)

Describe current physical health:  [  ] Good  [  ] Fair   [  ] Poor                                Is there a history of any of the following in the family:

                                                                                                                                                     [  ] tuberculosis                     [  ] heart disease

List name of primary care physician:                                                                           [  ] birth defects                    [  ] high blood pressure

Name                                                                     Phone                                                          [  ] emotional problems     [  ] alcoholism

                                                                                                                                                     [  ] behavior problems        [  ] drug abuse

List name of psychiatrist: (if any):                                                                                 [  ] thyroid problems           [  ] diabetes

Name                                                                     Phone                                                          [  ] cancer                                [  ] Alzheimer's disease/dementia

                                                                                                                                                     [  ] mental retardation         [  ] stroke

List any medications currently being taken (give dosage & reason):                  [  ] other chronic or serious health problems                                      

                                                                                                                                                                                                                                                                              

                                                                                                                                

                                                                                                                                                     Describe any serious hospitalization or accidents:

                                                                                                                                                     Date                            Age                  Reason                                              

List any known allergies:                                                                                                   Date                            Age                  Reason                                              

                                                                                                                                                     Date:                           Age                  Reason                                              

List any abnormal lab test results:

Date                                        Result                                                

Date                                        Result                                                

 

SUBSTANCE USE HISTORY (check all that apply for patient)

Family alcohol/drug abuse history:                        Substances used:                                                                           Current Use

                                                                                               (complete all that apply)                 First use age     Last use age    (Yes/No)   Frequency  Amount

[  ] father                   [  ] stepparent/live-in                  [  ] alcohol                                                                                                                                                

[  ] mother                 [  ] uncle(s)/aunt(s)                       [  ] amphetamines/speed                                                                                                                       

[  ] grandparent(s)   [  ] spouse/significant other      [  ] barbiturates/owners                                                                                                                         

[  ] sibling(s)           [  ] children                                     [  ] caffeine                                                                                                                                                

[  ] other                                                                               [  ] cocaine                                                                                                                                                

                                                                                               [  ] crack cocaine                                                                                                                                     

Substance use status:                                                     [  ] hallucinogens (e.g., LSD)                                                                                                              

                                                                                               [  ] inhalants (e.g., glue, gas)                                                                                                              

[  ] no history of abuse                                                    [  ] marijuana or hashish                                                                                                                       

[  ] active abuse                                                                  [  ] nicotine/cigarettes                                                                                                                           

[  ] early full remission                                                    [  ] PCP                                                                                                                                                       

[  ] early partial remission                                              [  ] prescription                                                                                                                                        

[  ] sustained full remission                                            [  ] other                                                                                                                                                     

[  ] sustained partial remission

 

Treatment history:                                                         Consequences of substance abuse (check all that apply):

 

[  ] outpatient (age[s]                                 )                     [  ] hangovers      [  ] withdrawal symptoms           [  ] sleep disturbance           [  ] binges

[  ] inpatient (age[s]                                   )                     [  ] seizures           [  ] medical conditions                 [  ] assaults                             [  ] job loss

[  ] 12-step program (age[s]                     )                     [  ] blackouts       [  ] tolerance changes                   [  ] suicidal impulse             [  ] arrests

[  ] stopped on own (age[s]                      )                     [  ] overdose         [  ] loss of control amount used              [  ] relationship conflicts

[  ] other (age[s]                                                                 [  ] other                                                                                                                                             

       describe:                                               

 

DEVELOPMENTAL HISTORY (check all that apply for a child/adolescent patient)

Problems during                     Birth:                                               Childhood health:

mother's pregnancy:             [  ] normal delivery                       [  ] chickenpox (age                     )                 [  ] lead poising (age                  )

                                                      [  ] difficult delivery                     [  ] German measles (age             )                 [  ] mumps (age                            )

[  ] none                                       [  ] cesarean delivery                    [  ] red measles (age                      )                 [  ] diphtheria (age                      )

[  ] high blood pressure           [  ] complications                          [  ] rheumatic fever (age               )                 [  ] poliomyelitis (age               )

[  ] kidney infection                                                                            [  ] whooping cough (age            )                 [  ] pneumonia (age                     )

[  ] German measles                      birth weight        lbs        oz.   [  ] scarlet fever (age                     )                 [  ] tuberculosis (age                   )

[  ] emotional stress                                                                           [  ] autism                                                          [  ] mental retardation

[  ] bleeding                                Infancy:                                          [  ] ear infections                                             [  ] asthma

[  ] alcohol use                           [  ] feeding problems                    [  ] allergies to                                                                                                               

[  ] drug use                                 [  ] sleep problems                        [  ] significant injuries                                                                                                

[  ] cigarette use                         [  ] toilet training problems       [  ] chronic, serious health problems                                                                                        

[  ] other                                                                                                                                                                                                                                            

 

Delayed developmental milestones (check only                 Emotional / behavior problems (check all that apply):

those milestones that did not occur at expected age):

                                                                                                            [  ] drug use                      [  ] repeats words of others       [  ] distrustful

[  ] sitting                                   [  ] controlling bowels            [  ] alcohol abuse           [  ] not trustworthy                     [  ] extreme worrier

[  ] rolling over                         [  ] sleeping alone                    [  ] chronic lying           [  ] hostile/angry mood             [  ] self-injurious acts

[  ] standing                                [  ] dressing self                        [  ] stealing                      [  ] indecisive                               [  ] impulsive

[  ] walking                                 [  ] engaging peers                   [  ] violent temper         [  ] immature                                 [  ] easily distracted

[  ] feeding self                          [  ] tolerating separation        [  ] fire-setting                [  ] bizarre behavior                   [  ] poor concentration

[  ] speaking words                   [  ] playing cooperatively      [  ] hyperactive               [  ] self-injurious threats           [  ] often sad

[  ] speaking sentences           [  ] riding tricycle                     [  ] animal cruelty          [  ] frequently tearful                  [  ] breaks things

[  ] controlling bladder            [  ] riding bicycle                      [  ] assaults others         [  ] frequently daydreams           [  ] other                            

[  ] other                                                                                         [  ] disobedient             [  ] lack of attachment                   _________________

 

Social interaction (check all that apply):                                                Intellectual / academic functioning (check all that apply):

[  ] normal social interaction   [  ] inappropriate sex play                     [  ] normal intelligence      [  ] authority conflicts        [  ] mild retardation

[  ] isolates self                            [  ] dominates others                               [  ] high intelligence           [  ] attention problems       [  ] moderate retardation

[  ] very shy                                  [  ] associates with acting-out peers   [  ] learning problems         [  ] underachieving               [  ] severe retardation

[  ] alienates self                          [  ] other                                                      Current  or highest education level                                                                              

 

Describe any other developmental problems or issues:                                                                                                                                                                                     

                                                                                                                                                                                                                                                                             

 

SOCIO-ECONOMIC  HISTORY (check all that apply for patient)

Living situation:                                      Social support system:                         Sexual history:

[  ] housing adequate                                 [  ] supportive network                           [  ] heterosexual orientation      [  ] currently sexually dissatisfied

[  ] homeless                                               [  ] few friends                                            [  ] homosexual orientation       [  ] age first sex experience              

[  ] housing overcrowded                         [  ] substance-use-based friends            [  ] bisexual orientation              [  ] age first pregnancy/fatherhood    

[  ] dependent on others for housing    [  ] no friends                                             [  ] currently sexually active      [  ] history of promiscuity age     to      

[  ] housing dangerous/deteriorating   [  ] distant from family of origin          [  ] currently sexually satisfied  [  ] history of unsafe sex age    to        

[  ] living companions dysfunctional                                                                       Additional information:                                                                                  

                                                                        Military history:

Employment:                                              [  ] never in military                                Cultural/spiritual/recreational history:

[  ] employed and satisfied                      [  ] served in military - no incident      cultural identity (e.g., ethnicity, religion):                                              

[  ] employed but dissatisfied                 [  ] served in military - with incident                                                                                                                                 

[  ] unemployed                                                                                                                 describe any cultural issues that contribute to current problem:          

[  ] coworker conflicts                                                                                                                                                                                                                                  

[  ] supervisor conflicts                           Legal history:                                          currently active in community/recreational activities? Yes [  ] No [  ]

[  ] unstable work history                       [  ] no legal problems                              formerly active in community/recreational activities? Yes [  ] No [  ]

[  ] disabled:                                                [  ] now on parole/probation                 currently engage in hobbies?                                          Yes [  ] No [  ]

                                                                        [  ] arrest(s) not substance-related        currently participate in spiritual activities?               Yes [  ] No [  ]

Financial situation:                                 [  ] arrest(s) substance-related               if answered "yes" to any of above, describe:                                             

[  ] no current financial problems         [  ] court ordered this treatment                                                                                                                                            

[  ] large indebtedness                              [  ] jail/prison                      time(s)                                                                                                                                       

[  ] poverty or below-poverty income        total time served:                               

[  ] impulsive spending                                  describe last legal difficulty:          

[  ] relationship conflicts over finances                                                                    

 

SOURCES OF DATA PROVIDED ABOVE: [  ] Patient self-report for all  [  ] A variety of sources (if so, check appropriate sources below):

Presenting Problems/Symptoms                   Family History                                                            Developmental History

[  ] patient self-report                                         [  ] patient self-report                                                  [  ] patient self-report

[  ] patientÕs parent/guardian                          [  ] patient's parent/guardian                                     [  ] patient's parent/guardian

[  ] other (specify)                                              [  ] other (specify)                                                        [  ] other (specify)                                              

Emotional/Psychiatric History                    Medical/Substance Use History                            Socioeconomic History

[  ] patient self-report                                       [  ] patient self-report                                                  [  ] patient self-report

[  ] patientÕs parent/guardian                          [  ] patient's parent/guardian                                     [  ] patient's parent/guardian

[  ] other (specify)                                              [  ] other (specify)                                                        [  ] other (specify)