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:

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