Patient Interview Template

8/10/2019 Patient Interview Template

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Patient Interview Template

IDENTIFYING INFORMATION

Age:

Sex:

Race:

Marital status:

Employment status:

CHIEF COMPLAINT/MAJOR LIFETIME PROBLEM(use patients own words)

HPI(include pertinent negatives, current psycotropic medications)

PAST PSYCHIATRIC HISTORY!nitial symptoms/symptoms not currently o" concern:


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#rior treatment and response to treatment:

$ter psyciatric disorders tat ave resolved:

FOCSED MEDICAL HISTORY

%urrent illnesses:

Medications:

Allergies:

#rior serious illness or surgeries:

Reproductive istory:

#ertinent negatives:

SBSTANCE SE HISTORY(pattern o" use, longest periods o" a&stinence, use o" sel"'elp or pro"essionalresources)

rugs:

Alcool:

%igarettes:

FAMILY PSYCHIATRY HISTORY("irst' and second'degree relatives)

Mental illnesses:

Suicides:

Su&stance a&use:

SOCIAL!DE"ELOPMENTAL HISTORY

amily o" origin:Mem&ers:

Etnic &ac*ground:

Social &ac*ground:


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Relationsip &etween parents:

#arents relationsip to cildren:

Ma+or li"e events (moves, divorces, deats):

Scool istory:

Early "riendsips:

Adolescent &eavior:

!ntimate relationsips:

%ollege/military istory:

Adult wor* istory:

Adult relationsips:

Marriages:

Relationsips wit cildren:

%urrent social situation:

%urrent +o& sta&ility:

inancial di""iculties/resources:

Supportive/pro&lematic relationsips:

MENTAL STATS E#AMINATION(include pertinent negatives)Appearanceress:

rooming:

-eigt:

Motor &eavior:


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Eye contact:

.evel o" consciousness:

Attitude toward interview:

Speec:

ougt process:

A""ect:

Mood:

#erceptions:

0allucinations:

!llusions:

ougt %ontent:

elusions:

!deas o" re"erence:

#reoccupations (main temes/concerns):

Suicidal/assaultive tougt, plans, intentions:

ormal cognitive tests:$rientation:

Attention:

%oncentration:

Registration and sort'term memory:

%alculations:

A&straction:

und o" *nowledge:

1oca&ulary:

!nsigt (into source o" symptoms or into personal motivations, 2ualities):

ested +udgment, personal +udgment:

MLTIA#IAL DIAGNOSIS

Axis !: Main provisional diagnoses, diagnoses to 3consider also4

Axis !!: #ossi&le maladaptive personality traits

Axis !!!: %urrent medical pro&lems, medical pro&lems contri&uting to current condition


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Axis !1: Main stressors

Axis 1: lo&al assessment o" "unction (use pu&lised scale in SM'!1)

#AE

#AE 5

"It sounds as if Holly has had a fever for a few days. Can you tell me a little more about her illness?"

"Has she had any runny nose, congestion, cough or difficulty breathing?"

"Has Holly had any vomiting or diarrhea?"

"Has Holly been urinating more frequently, has she had any blood in her urine, or has her urine had

any unusual odor?"

"Has she had any skin rashes or sores in her mouth?"

"You said Holly was fussy. oes she res!ond to you when you try to comfort her? oes she

recognie you and other familiar faces?"

"Has Holly had any recent trauma?"

"Has Holly had any redness or swelling of her #oints or e$tremities?"

The term fever without source %&'is used when a complete history has been

obtained and a detailed physical examination performed, and there is no identified

source of the child's fever.

(ever )ithout *ource


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Far and away the most common cause of fever without source in this age group is a viral syndrome. A small

minority of children, however, may have aserious bacterial illness (S!". #tiologies of S!

include the following$

% &rinary tract infection (&T!"the most common

% eningitis% Sepsis

% )neumonia

% acterial gastroenteritis

% *steomyelitis

% Septic arthritis

% *ccult bacteremia

%

Fever of un+nown origin (A" is defined as a temperature greater than -. (/0/ F" for at least two wee+s'

duration with failure to reach a diagnosis after one wee+ of evaluation.

Sepsis (" is a severe systemic illness caused by overwhelming infection of the bloodstream by toxin

producing bacteria. A diagnosis of sepsis typically re1uires positive blood cultures.

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Patient Interview Template