Comprehensive Biopsychosocial/Medical History Form: Version 1.0
Courtesy of Dr. Katherine Day


I Patient name:

II Identifying data:

III Chief complaint:

IV Duration:

V History of presenting illness:

 

 

 

 

VI Past psychiatric history:
Hospitalizations:

 

Medications medicine dose/freq started stopped indication
1.

 

 

 

 

 

 

2.

 

 

 

 

 

 

3.

 

 

 

 

 

 

4.

 

 

 

 

 

 

5.

 

 

 

 

 

 

Psychotherapy:

 

VII Family history:
Psychiatric:

 

 

Medical:

 

 

VIII Past medical history:
Head injuries:

Seizures:

Significant illness:

 

 

Significant surgeries:

 

 

Allergies:

Alcohol use:

Smoking:

Drug use:

Last menstrual period:

Current medications dose/freq started stopped indication
1.

 

 

 

2.

 

 

 

3.

 

 

 

4.

 

 

 

5.

 

 

 

(Please include information regarding nonprescription drugs in addition to prescription drugs)

IX Mental status:
Orientation:

Memory:

Behavior:

Appearance:

Mood:

Speech:

Affect:

Suicidal ideation:

Psychotic symptoms:

X Diagnosis:

 

 

XI Plan:

 

 

 

Other relevant information:

 

 

 

Signature of clinician Date

ShrinksOnline