Psychiatric History Assignment Template
S: Subjective
Information the client or representative told you
Initials: SJ Age: 21 Gender: M
Include vital signs if provided. State not provided here if not available. Not provided
Allergies (and reaction) Sulfa Medications
Medication: N/a
Food: Fast food most of the time. Decreased appetite Regular diet
Environment: Safe for interview Outpatient Clinic
History of Present Illness (HPI)
Chief Complaint (CC) CC is a BRIEF statement identifying
“I haven’t been feeling like myself and haven’t had a lot of energy to do the things I enjoy why the client is here - in the patient’s
HPI own words - for instance "I have been
After losing the college basketball scholarship he started having feelings of helplessness and hopeless especially feeling depressed," NOT "symptoms of
when found out he would need surgery. This sent him into isolation, refused friends, visitation and phone calls. He depression for 3 weeks.” History of
didn’t want to do anything but sleep. He tried to continue to be strong and finish college however was unsuccessful Present Illness (HPI)
because of excessive substance abuse. Marijuana is the drug of choice he has never tried any other substances. SJ (1) develops illness narrative: (cogent
continues to smoke daily. story with clear chronology, not a
Dad passed away and lost a child this same year. Now looking around at the life he has it doesn’t feel like it’s his. list of symptoms), and
States doesn’t feel like he should be sad because life and death is normal. Has had accomplishments promotion at (2) includes specific details of
work but refused. 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. State NA if
no current medications.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Ondansetron(Zofran) 4 mg PRN 2 weeks Nausea and vomiting d/t THC
overuse
Escitalopram(Lexapro) 10 mg Daily 1 month Depression
Levothyroxine (Synthroid) 12.5 mg Daily 1 month Hypothyroidism
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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.
After the death of father 2 months ago, was hospitalized for depression and thoughts of suicide, no plan.
He never has had counseling because doesn’t believe it doesn’t work. Culturally does not believe that talking out the problems help. Also has never stayed consistent with one
provider. He has communicated that no provider has made him feel safe to continue care and never has felt heard.
Medications in the past: Escitalopram (Lexapro) stopped taking due to unable to satisfy his girlfriend, was given this upon discharge from the hospital after feelings of self-harm.
Only took for about 1 month until unable to satisfy her and she broke up with him because of it. Took levothyroxine for the full prescription but never went back to fill
prescription after completing. Medical referral may be necessary.
He currently is not taking medications currently for mental health or sleep
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.
Patient has had a THC hospitalization d/t over use causing nausea and vomiting. Fractured collarbone requiring surgery which ended his college career.
Depression causing for psych hold d/t thoughts of harming self after the death of father and child.
Pt states he has Hypothyroidism however he is noncompliant with medication Synthroid, because he didn’t have the energy to go fill the prescription.
Family History (Fam Hx) - History includes, but it 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, siblings, and children. Include
grandchildren if pertinent.
Mother- No history of psychiatric disorder, Father: unknown if psychiatric condition. Sister diagnosed with schizophrenia, after the
death of father. Had her daughter taken into custody no contact. Grandmother (fathers’ side) no psychiatric history. Grandmother
(father’s side) no psychiatric
S: Subjective
Information the client or representative told you
Initials: SJ Age: 21 Gender: M
Include vital signs if provided. State not provided here if not available. Not provided
Allergies (and reaction) Sulfa Medications
Medication: N/a
Food: Fast food most of the time. Decreased appetite Regular diet
Environment: Safe for interview Outpatient Clinic
History of Present Illness (HPI)
Chief Complaint (CC) CC is a BRIEF statement identifying
“I haven’t been feeling like myself and haven’t had a lot of energy to do the things I enjoy why the client is here - in the patient’s
HPI own words - for instance "I have been
After losing the college basketball scholarship he started having feelings of helplessness and hopeless especially feeling depressed," NOT "symptoms of
when found out he would need surgery. This sent him into isolation, refused friends, visitation and phone calls. He depression for 3 weeks.” History of
didn’t want to do anything but sleep. He tried to continue to be strong and finish college however was unsuccessful Present Illness (HPI)
because of excessive substance abuse. Marijuana is the drug of choice he has never tried any other substances. SJ (1) develops illness narrative: (cogent
continues to smoke daily. story with clear chronology, not a
Dad passed away and lost a child this same year. Now looking around at the life he has it doesn’t feel like it’s his. list of symptoms), and
States doesn’t feel like he should be sad because life and death is normal. Has had accomplishments promotion at (2) includes specific details of
work but refused. 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. State NA if
no current medications.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Ondansetron(Zofran) 4 mg PRN 2 weeks Nausea and vomiting d/t THC
overuse
Escitalopram(Lexapro) 10 mg Daily 1 month Depression
Levothyroxine (Synthroid) 12.5 mg Daily 1 month Hypothyroidism
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text. enter text. text. here
to enter text.
Click or tap here to enter Click or tap here to Click or tap here to Click or tap Click or tap here to enter text.
text. enter text. enter text. here to enter
text.
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.
After the death of father 2 months ago, was hospitalized for depression and thoughts of suicide, no plan.
He never has had counseling because doesn’t believe it doesn’t work. Culturally does not believe that talking out the problems help. Also has never stayed consistent with one
provider. He has communicated that no provider has made him feel safe to continue care and never has felt heard.
Medications in the past: Escitalopram (Lexapro) stopped taking due to unable to satisfy his girlfriend, was given this upon discharge from the hospital after feelings of self-harm.
Only took for about 1 month until unable to satisfy her and she broke up with him because of it. Took levothyroxine for the full prescription but never went back to fill
prescription after completing. Medical referral may be necessary.
He currently is not taking medications currently for mental health or sleep
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.
Patient has had a THC hospitalization d/t over use causing nausea and vomiting. Fractured collarbone requiring surgery which ended his college career.
Depression causing for psych hold d/t thoughts of harming self after the death of father and child.
Pt states he has Hypothyroidism however he is noncompliant with medication Synthroid, because he didn’t have the energy to go fill the prescription.
Family History (Fam Hx) - History includes, but it 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, siblings, and children. Include
grandchildren if pertinent.
Mother- No history of psychiatric disorder, Father: unknown if psychiatric condition. Sister diagnosed with schizophrenia, after the
death of father. Had her daughter taken into custody no contact. Grandmother (fathers’ side) no psychiatric history. Grandmother
(father’s side) no psychiatric
