Name: Jan Arthur Elpa
Psychiatric Interview Template
S: Subjective
(Information the client or representative told you)
Initials: K.S Age: 54 Gender: Male
Include vital signs if provided . Document not provided if not available.
Height Weight Allergies (and reaction)
5 ft 9in 150 lbs Medication: none
Food: shellfish-anaphylaxis
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) CC is a BRIEF statement identifying
“I’m here to see another provider due to shortage at the VA” why the client is here - in the patient’s
own words - for instance "I have been
HPI feeling depressed," NOT "symptoms of
Patient came to visit to establish care due to recent shortage of providers in the VA, which he was depression for 3 weeks.” History of
receiving care from for about 15 years. Pt has a past history of depression, 20-22 years, but is currently Present Illness (HPI)
being treated for Bipolar disorder, due to a “break” he had around year 2000s. Pt is reports feeling stable (1) Develops illness narrative (cogent
on his current medication regimen of Lithium and Wellbutrin. Pt would like to refill upcoming medications story with clear chronology, not a
and to resume his treatment plan from the VA. Pt reports good sleep, good appetite and reports feeling list of symptoms), and
stable and wants to maintain being stable. (2) includes specific details of
symptoms, and the impact of these
symptoms on daily life.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Lithium 900mg Daily at bedtime 15 years Bipolar Disorder
Wellbutrin – sustained release 300mg Daily in the Morning 6 months ago Depressive Symptoms
Synthroid Unsure of Dose Daily in the morning, on Click or tap here Hypothyroidism
empty stomach to enter text.
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, Name: Jan Arthur Elpa
Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include
type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others.
-Pt was a military physician with diagnosis of depression about 20-22 years ago and is currently being treated for bipolar disorder. Pt has been
receiving care from the VA for about 15 years now. Around year 2000, patient experienced “break” due to “long shifts”, “on call for a whole week”,
“bad patients”, and “couple of bad outcomes.” He was reevaluated and hospitalized during that time.
-Patient’s last psychiatrist was unsure if bipolar disorder is KS true diagnosis.
-The patient has been on lithium for about 15 years, the last adjustment was 10 years ago. The last lithium blood level was within normal limits and
was from 6 months ago.
-Pt reports improved sleep and less anxiety with Wellbutrin for the last 6 months
-Reported childhood trauma of physical and verbal abuse from mother due to mother’s diagnosis
-In 1998, Wife noticed behavior such as hyper-focused, extra energy, not sleeping enough, and need to finish tasks but no ADHD official diagnosis
Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any
intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypothyroidism – Synthroid Unknown dose. Once a day,
Family History (Fam Hx) - History includes but is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses.
Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents (if information was provided), siblings,
and children. Include grandchildren if pertinent.
Mother, deceased, Medical history of Breast Cancer, died from cancer in her 80s
Psychiatric history of psychotic break, hospitalized for numerous times, Mother would have depressive symptoms for a couple of days, and then
another day would have manic phases, labile and become verbally abusive. Mom has a history of auditory hallucinations. Mother was non-
compliant with medications. Diagnosis of bipolar disorder or “Borderline schizophrenic”
Father, alive (91y/o)– no Hx of mental illness, Diabetes
Brother, alive (53y/o) – history of mild depression after his divorce
Daughter, 19 – no medical history
Daughter, 21 – no medical history, Hx of mild depression
Daughter, 23 – no medical history
Social History (Soc Hx) - History includes but not limited to education, occupation, current employment (If not currently working, when was last
time client was employed and what was the reason for stopping?), current living arrangements, hobbies, relationship status, tobacco, alcohol and
Psychiatric Interview Template
S: Subjective
(Information the client or representative told you)
Initials: K.S Age: 54 Gender: Male
Include vital signs if provided . Document not provided if not available.
Height Weight Allergies (and reaction)
5 ft 9in 150 lbs Medication: none
Food: shellfish-anaphylaxis
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) CC is a BRIEF statement identifying
“I’m here to see another provider due to shortage at the VA” why the client is here - in the patient’s
own words - for instance "I have been
HPI feeling depressed," NOT "symptoms of
Patient came to visit to establish care due to recent shortage of providers in the VA, which he was depression for 3 weeks.” History of
receiving care from for about 15 years. Pt has a past history of depression, 20-22 years, but is currently Present Illness (HPI)
being treated for Bipolar disorder, due to a “break” he had around year 2000s. Pt is reports feeling stable (1) Develops illness narrative (cogent
on his current medication regimen of Lithium and Wellbutrin. Pt would like to refill upcoming medications story with clear chronology, not a
and to resume his treatment plan from the VA. Pt reports good sleep, good appetite and reports feeling list of symptoms), and
stable and wants to maintain being stable. (2) includes specific details of
symptoms, and the impact of these
symptoms on daily life.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Lithium 900mg Daily at bedtime 15 years Bipolar Disorder
Wellbutrin – sustained release 300mg Daily in the Morning 6 months ago Depressive Symptoms
Synthroid Unsure of Dose Daily in the morning, on Click or tap here Hypothyroidism
empty stomach to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
, Name: Jan Arthur Elpa
Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include
type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others.
-Pt was a military physician with diagnosis of depression about 20-22 years ago and is currently being treated for bipolar disorder. Pt has been
receiving care from the VA for about 15 years now. Around year 2000, patient experienced “break” due to “long shifts”, “on call for a whole week”,
“bad patients”, and “couple of bad outcomes.” He was reevaluated and hospitalized during that time.
-Patient’s last psychiatrist was unsure if bipolar disorder is KS true diagnosis.
-The patient has been on lithium for about 15 years, the last adjustment was 10 years ago. The last lithium blood level was within normal limits and
was from 6 months ago.
-Pt reports improved sleep and less anxiety with Wellbutrin for the last 6 months
-Reported childhood trauma of physical and verbal abuse from mother due to mother’s diagnosis
-In 1998, Wife noticed behavior such as hyper-focused, extra energy, not sleeping enough, and need to finish tasks but no ADHD official diagnosis
Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any
intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Hypothyroidism – Synthroid Unknown dose. Once a day,
Family History (Fam Hx) - History includes but is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses.
Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents (if information was provided), siblings,
and children. Include grandchildren if pertinent.
Mother, deceased, Medical history of Breast Cancer, died from cancer in her 80s
Psychiatric history of psychotic break, hospitalized for numerous times, Mother would have depressive symptoms for a couple of days, and then
another day would have manic phases, labile and become verbally abusive. Mom has a history of auditory hallucinations. Mother was non-
compliant with medications. Diagnosis of bipolar disorder or “Borderline schizophrenic”
Father, alive (91y/o)– no Hx of mental illness, Diabetes
Brother, alive (53y/o) – history of mild depression after his divorce
Daughter, 19 – no medical history
Daughter, 21 – no medical history, Hx of mild depression
Daughter, 23 – no medical history
Social History (Soc Hx) - History includes but not limited to education, occupation, current employment (If not currently working, when was last
time client was employed and what was the reason for stopping?), current living arrangements, hobbies, relationship status, tobacco, alcohol and
