Psychiatry Forms

Psychiatry Packet

Psychiatry Packet

Current Symptoms Checklist:
General Stress Level:

Suicide Assessment:

Do you have access to guns?
Have you ever had feelings or thoughts that you didn’t want to live?
If you answered no, skip to “Past Psychiatric History” section. If yes, continue. Do you currently feel that you don’t want to live?

Past Psychiatric History:

Outpatient treatment?
Psychiatric Hospitalization?

Past Psychiatric Medications

If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can’t remember all the details, just write in what you do remember)


Mood Stabilizers:

Antipsychotics/Mood Stabilizers:


ADHD Medications:

Antianxiety Medications:

Has any family members been treated with a psychiatric medication?

Personal and Family Medical History:

*Please indicate if it was YOU, or Family Member(s), as well as the Doctor/Facility that did the diagnosis)* **Please limit this to the first degree relatives.**

Educational History:

Did you attend college?


Trauma History:

Do you have a history of being abused emotionally, sexually, physically, or by neglect?

Substance Abuse:

Have you ever been treated for alcohol or drug use or abuse?

Check if you have ever tried the following:

Have you ever tried Methamphetamine?
Have you ever tried Cocaine?
Have you ever tried Stimulants (pills)?
Have you ever tried Heroin?
Have you ever tried LSD or Hallucinogens?
Have you ever tried Marijuana?
Have you ever tried Pain Killers (not prescribed)?
Have you ever tried Methadone?
Have you ever tried Alcohol?
Have you ever tried Ecstasy?
Have you ever tried Steroids?
Have you ever tried Tranquilizer/sleeping pills?
Have you ever tried Other?

Occupational History:

Are you currently:
Have you ever served in the military?
Honorable discharge?

Family Background and Childhood History?

Were you adopted?
Did your parents divorce?

Relationship History and Current Family:

Are you currently:
If not married, are you currently in a relationship?
Are you sexually active?
How would you identify your sexual orientation?
Have you had any other prior marriages?
Do you have children?

Legal History:

Have you ever been arrested?
Do you have any pending legal problems?

Spiritual Life:

Do you belong to a religion or spiritual group?
Do you find your involvement helpful during this illness, or does the involvement make things more difficult or stressful for you?

Miscellaneous Medical Information:

Are you legally blind?
Are you deaf?

Mood Disorder Questionnaire:

Has there ever been a period of time when you were not your usual self and …

… you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
… you were so irritable that you shouted at people or started fights or arguments?
… you felt much more self-confident than usual?
… you got much less sleep than usual and found you didn’t really miss it?
… you were much more talkative or spoke faster than usual?
… thoughts raced through your head or you couldn’t slow your mind down?
… you were so easily distracted by things around you that you had trouble concentrating or staying on track?
… you had much more energy than usual?
… you were much more active or did many more things than usual?
… you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
… you were much more interested in sex than usual?
… you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
… spending money got you or your family in trouble?
If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
How much of a problem did any of these cause you – like being able to work; having family, money, or legal troubles; getting into arguments or fights? Please check 1 response only:
Have any of your blood relatives [ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
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