Free Initial Psychiatric Evaluation Template
Initial Psychiatric Evaluation
[Your Company Name]
Date: _____________________
Patient's Information
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Category |
Information |
|---|---|
|
Patient Name |
[Patient's Full Name] |
|
Date of Birth |
[Patient's Date of Birth] |
|
Gender |
[Patient's Gender] |
|
Contact Information |
[Patient's Phone Number] |
Introduction: Mental health professionals use this document to extensively evaluate a patient's condition, including psychiatric symptoms, medical and family history, substance use, and psychosocial stressors, to better understand their mental health and plan suitable treatment.
Overview: This assessment comprises of Psychiatric symptoms evaluation (duration, severity, onset, past treatments), Medical history review (relevant past/current conditions), Family history examination (genetic predispositions, hereditary mental issues), Substance use analysis, and identification of psychosocial stressors impacting the patient's mental health.
Each criterion will be evaluated based on the provided guidelines and metrics.
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Criteria |
Observation |
|---|---|
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Psychiatric Symptoms
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Medical History
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Family History
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Psychosocial Stressors
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Additional Comments & Notes
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Observations |
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