Download Biopsychosocial History

Patient name
Date
Tara Benincasa, LMHC, NCC
3761 Carman Road
Schenectady, NY 12303
BIOPSYCHOSOCIAL HISTORY
PRESENTING PROBLEMS
1. Presenting Problem
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2.
History of Presenting Problem
Frequency/duration/severity/cycling of symptoms: _____________________________________________________________________________
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Family mental health history: ______________________________________________________________________________________________
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CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)
None This symptom not present at this time • Mild Impacts quality of life, but no significant impairment of day-to-day functioning
Moderate Significant impact on quality of life and/or day-to-day functioning • Severe Profound impact on quality of life and/or day-to-day
functioning
SYMPTOM
Depressed Mood
Appetite Disturbance
Significant Weight Loss/Gain
Sleep Disturbance
Fatigue/Low Energy
Loss of Interest in Activities
Social Isolation
Poor Concentration
Poor Grooming
Eating Disorders
Somatic Complaints
Guilt
Worthlessness
Hoplessness
Grief
Elevated Mood/Mania
Hyperactivity
Trauma Victim Emotiona/Physical/Sexual/Mental
Non-Suicidal Self-Injury (i.e.
Cutting)
MILD
MODERATE
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SEVERE
NONE
Patient name
Date
Mood Swings
Substance/Alcohol Abuse
Aggressive Behaviors
Irritability/Agitation
Aggressive Behaviors
Oppositional Behaviors
Emotionality (i.e. Excessive
Crying)
Generalized Anxiety
Panic Attacks
Obsessions/Compulsions
EMOTIONAL/PSYCHIATRIC HISTORY
[ ] [ ] Prior outpatient psychotherapy?
No Yes
Prior provider name
City
State
Diagnosis
Beneficial?
____________
__________________________
[ ] [ ] Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?
No Yes
Inpatient facility name City
State
Diagnosis
Beneficial?
____________
__________________________
[ ] [ ] Prior or current psychotropic medication usage? If yes:
No Yes Medication
Dosage
Frequency Start date End date
________________________
________________________
MEDICAL HISTORY (check all that apply for patient)
Describe current physical health: [ ] Good [ ] Fair [ ] Poor
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Physician
____________
Beneficial?
__________
__________
List name of psychiatrist: (if any):
Name: _________________________ Phone: ________________
List any medications currently taking (give dosage & reason):
______________________________________________________
_________________________________________
_________________________________________
SUBSTANCE USE HISTORY (check all that apply for patient)
Substance use status:
[ ] NO HISTORY OF ABUSE
[ ] active abuse
[ ] early full remission
[ ] early partial remission
[ ] sustained full remission
[ ] sustained partial remission
Consequences of substance abuse (check all that apply):
[ ] hangovers
[ ] withdrawal symptoms
[ ] seizures
[ ] medical conditions
[ ] suicidal impulse
[ ] arrests
[ ] relationship conflicts
[ ] other
Treatment history:
[ ] outpatient (age[s] )
[ ] inpatient (age[s] )
[ ] 12-step program (age[s]
[ ] stopped on own (age[s]
[ ] sleep disturbance
[ ] assaults
[ ] overdose
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)
)
[ ] binges
[ ] blackouts
[ ] job loss
[ ] tolerance changes
[ ] loss of control amount used
Patient name
Date
DEVELOPMENTAL HISTORY (check all that apply for a child/adolescent patient)
Emotional / behavior problems (check all that apply):
[ ] drug use
[ ] repeats words of others
[ ] alcohol abuse
[ ] not trustworthy
[ ] chronic lying
[ ] hostile/angry mood
[ ] stealing
[ ] indecisive
[ ] violent temper
[ ] immature
[ ] fire-setting
[ ] self-injurious acts
[ ] hyperactive
[ ] self-injurious threats
[ ] animal cruelty
[ ] frequently tearful
[ ] assaults others
[ ] frequently daydreams
[
[
[
[
[
[
[
] distrustful
] lack of attachment
] breaks things
] impulsive
] easily distracted
] poor concentration
] often sad
Social interaction (check all that apply):
[ ] normal social interaction [ ] inappropriate sex play
[ ] isolates self
[ ] dominates others
[ ] very shy
[ ] associates with acting-out peers
[ ] alienates self
[ ] other ____________________
Intellectual / academic functioning (check all that apply):
[ ] normal intelligence
[ ] high intelligence
[ ] learning problems
[ ] authority conflicts
[ ] attention problems
[ ] underachieving
[ ] mild retardation
[ ] moderate retardation
[ ] severe retardation
School Name __________________________________________________________
Describe any other developmental problem or
issue: ________________________________
Grade _______________________________
Special Education Services ________________________________________________________________________________________________
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