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Clinical Psych History Template

This clinical record form collects information about a patient's medical history, current symptoms, mental status, medications, and treatment plan. It includes sections for identifying information, vital signs, medical conditions, medications, allergies, presenting problems, family history, systems review, mental health history, substance use, mental status examination, cognitive functioning, judgement and insight. Progress notes are documented to track the patient's progress towards treatment goals, interventions used, and plans for follow up care.

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Vlad Iliescu
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
24 views5 pages

Clinical Psych History Template

This clinical record form collects information about a patient's medical history, current symptoms, mental status, medications, and treatment plan. It includes sections for identifying information, vital signs, medical conditions, medications, allergies, presenting problems, family history, systems review, mental health history, substance use, mental status examination, cognitive functioning, judgement and insight. Progress notes are documented to track the patient's progress towards treatment goals, interventions used, and plans for follow up care.

Uploaded by

Vlad Iliescu
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

CLINICAL RECORD FORM

Patient ID: ___________________________________________Date of Birth: ___/___/___   Age:

Sex: □ Male   □  Female

City: _________________________________________________

Marital Status: □ Married     □ Single     □ Divorced     □ Widowed

Check blood pressure, temperature and pulse.

Current Medical Conditions:

Current Medications, Herbal Supplements & Vitamins (Daily Dose, Start Date):

Allergies/Adverse Reactions to Treatment:

Presenting Problem:
What kind of symptoms have you noticed?
When did they begin?
How often do they happen?
Have they gotten worse?

Family history and Past Medical History:

1
EYE SIGHT TEST: (DOUBLE VISION?) Y/N

PAIN REPORTED:

EATING AND SWALLOWING:

HEARING PROBLEMS:

NUMBNESS:

CHEST PAIN:

SHORTNESS OF BREATH:

HEART PAIN:

LEG PAIN:

TUMMY PAIN:

COUGH:

URINATION:

Prior and Current Treatment for Mental Health:

Past and Present Use of Cigarettes, Alcohol and Other Substances (Date of First Use, Most Recent Use, Use in
Past 3 Months; Legal, Vocational and Family Consequences):

CURRENT MENTAL STATUS EVALUATION:


2
APPEARANCE: [ ] Well-groomed [ ] Disheveled [ ] Bizarre [ ] Inappropriate

ATTITUDE: [ ] Cooperative [ ] Guarded [ ] Suspicious [ ] Uncooperative


[ ] Belligerent [ ] Other ________________________________________________

MOTOR ACTIVITY: [ ] Calm [ ] Hyperactive [ ] Agitated [ ] Tremors/Tics


[ ] Muscle spasms [ ] Other _________________________________________________

AFFECT: [ ] Appropriate [ ] Labile [ ] Expansive [ ] Constricted


[ ] Blunted [ ] Flat [ ] Worrisome [ ] Sad [ ] Apathetic

MOOD: [ ] Euthymic [ ] Depressed [ ] Anxious [ ] Euphoric [ ] Angry

SPEECH: [ ] Normal [ ] Delayed [ ] Soft [ ] Loud [ ] Slurred


[ ] Excessive [ ] Pressured [ ] Incoherent [ ] Persevering

THOUGHT PROCESS: [ ] Intact [ ] Circumstantial [ ] Tangential [ ] Flight of ideas


[ ] Loose associations
[ ] Other

THOUGHT CONTENT:

Hallucinations: [ ] Not present [ ] Present


If Present, describe: ________________________________________________________

Delusions: [ ] Not present [ ] Present


If Present, describe: ________________________________________________________

ORIENTATION: [ ] Fully oriented [ ] Disoriented


If Disoriented, describe:_____________________________________________________

MEMORY: Long-Term [ ] Intact [ ] Impaired


Short-Term [ ] Intact [ ] Impaired
If Impaired, describe: ______________________________________________________

COGNITIVE FUNCTION:

General Knowledge: [ ] Intact [ ] Somewhat intact [ ] Not intact


Serial Sevens/Calculations: [ ] Intact [ ] Somewhat intact [ ] Not intact
Abstract Thinking: [ ] Intact [ ] Somewhat intact [ ] Not intact

JUDGEMENT: [ ] Intact [ ] Impaired – [ ] Mild [ ] Moderate [ ] Severe

INSIGHT: [ ] Intact [ ] Impaired – [ ] Mild [ ] Moderate [ ] Severe

3
Mental Status Comments:

Provide date of initial prescription, name and dosage, instructions and if applicable, dates of refill.
Date Medication Name Dosage Instructions Refills

4
PROGRESS NOTES
Session #: ____

Patient ID: ___________________________________________Date of Birth: ___/___/___   Age:

Patient progress towards goals (including patient’s strengths/limitations):

Interventions and patient’s response:

Revised goals or interventions:

Follow-up appointment date:

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