Comprehensive Psychiatric Medical History Form

Patient Information

• Full Name: _________________________
• Date of Birth: //___
• Gender: ________
• Today's Date: //___

Chief Complaint

What is the main reason for your visit today?

Current Symptoms Checklist

Please check all that apply:

Mood Symptoms

□ Depressed mood □ Loss of interest □ Changes in sleep □ Changes in appetite □ Fatigue □ Guilt/worthlessness

Anxiety Symptoms

□ Excessive worry □ Panic attacks □ Social anxiety □ Specific fears/phobias

Other Symptoms

□ Hallucinations □ Delusions □ Racing thoughts □ Impulsivity □ Concentration problems

Psychiatric History

Previous Mental Health Treatment

• Previous outpatient therapy? □ Yes □ No
• Previous psychiatric hospitalizations? □ Yes □ No
• Previous medication trials: _________________

Medical History

General Health

• Current medical conditions: ________________
• Current medications: _____________________
• Allergies: _____________________________

Family History

Mental Health History in Family

□ Depression □ Anxiety □ Bipolar Disorder □ Schizophrenia □ Substance Use □ Other: _______

Social History

• Marital Status: ________
• Employment: _________
• Education Level: ______
• Substance Use:
  • Alcohol: □ Yes □ No
  • Tobacco: □ Yes □ No
  • Other substances: _______

Safety Assessment

• Current thoughts of self-harm? □ Yes □ No
• Current thoughts of harming others? □ Yes □ No
• Past suicide attempts? □ Yes □ No

Additional Information

Signature

Patient/Guardian: _____________ Date: //___