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:

 

 

 

Signature of clinician	Date