Biopsychosocial History: Presenting Problems

Name: Judy Sample
1/26/2016
ID: 1
Page #: 1
SSN: 555-55-5555
Birthday: 7/7/1946
Date:
Biopsychosocial History
Presenting Problems
Primary Anxiety
Secondary Chronic Pain
Current Symptom Checklist (Rate intensity of symptoms currently present)

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
Impact
Emotional/Psychiatric History
Prior outpatient psychotherapy?

If yes, on occasions. Longest treatment by for sessions from to
Prior provider
name
City
State
Diagnosis
Intervention/Modality
Has any family member had outpatient psychotherapy?

If yes, who/why (list all):
Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?

If yes, on occasions. Longest treatment at from to
Inpatient facility
name
City
Diagnosis
Intervention/Modality
Beneficial?
Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes, who/why (list
all):
Prior or current psychotropic medication usage? If yes:
Medication
Xanax
State
Beneficial?
Dosage
5mg.
Frequency
1x/day
Start Date
8/7/2006
End Date
Physician
Dr.Jones
Has any family member used psychotropic medications? If yes, who/what/why (list all):
Family History
Family of Origin
Present during childhood
mother
father
Describe parents
Father
full name
Mother
Name: Judy Sample

1/26/2016
stepmother
stepfather
brother(s)
sister(s)
other
ID: 1
Page #: 2
SSN: 555-55-5555
Birthday: 7/7/1946
occupation
education
general health
specify other
Parents' current marital status

married to each other
Describe childhood family experience

outstanding home environment
separated for years

divorced for years
mother remarried times
father remarried times
normal home environment

chaotic home environment
witnessed physical/verbal/sexual abuse toward others
experienced physical/verbal/sexual abuse from others
mother involved with someone

father involved with someone
mother deceased for years
age of patient at mother's death
father deceased for years
age of patient at father's death
Age of emancipation from home:

Circumstances that contribute to emancipation
Special circumstances in childhood
Immediate Family
marital status
intimate relationship
relationship satisfaction
Married
List all persons currently living in patient's household

Name
Age
Sex
Relationship to Patient
List biological / adopted children not living in same household as patient

Name
Age
Sex
Relationship to Patient
Frequency of visitation of above:

Describe any past or current significant issues in intimate relationships
Describe any past or current significant issues in other immediate family relationships
Medical History
Describe current physical health
List name of primary care physician

Name Dr Smith
Phone
Date:
Name: Judy Sample

1/26/2016
ID: 1
Page #: 3
SSN: 555-55-5555
List name of psychiatrist (if any):

Name
Birthday: 7/7/1946
Phone
List any non-psychiatric medications currently being taken (give dosage & reason)
List any known allergies
Is there a history of any of the following in the family

tuberculosis
heart disease
birth
defects
high blood pressure
emotional problems
behavior problems
thyroid problems
cancer
mental retardation
alcoholism
drug abuse
diabetes
Alzheimer's disease/dementia
stroke
other chronic or serious health problems
Describe any serious hospitalization or accidents

Year
Age
Reason
List any abnormal lab test results

Year
Result
Substance Use History

Family alcohol/drug abuse history
father
sibling(s)
other
specify other:
mother
grandparent(s)
Substance use status
no history of abuse
active abuse
early full remission
early partial remission
sustained full remission
sustained partial remission
Patient Treatment history

outpatient
inpatient
12-step program
stopped on own
other
(age[s])
(age[s])
(age[s])
(age[s])
(age[s])
stepparent/live-in
uncle(s)/aunt(s)
spouse/significant other
children
Date:
Name: Judy Sample

1/26/2016
Substances
used
ID: 1
Page #: 4
First use age
Last use age
SSN: 555-55-5555
Current Use
Frequency
barbiturates/downers
cocaine
crack cocaine
hallucinogens (e.g., LSD)
inhalants (e.g., glue, gas)
marijuana or hashish
opioids
PCP
prescription
other
Date:
Amount
alcohol
amphetamines/speed
Birthday: 7/7/1946
Consequences of substance abuse
hangovers
seizures
blackouts
Accidental overdose
binges
withdrawal symptoms
medical conditions
Increase in tolerance
loss of control over amount used
job loss
suicide attempts
suicidal impulse/thoughts
relationship conflicts
arrests
sleep disturbance
assaults
other
Developmental History
Problems during mother's pregnancy
Birth
Infancy Problems
none
high blood pressure
kidney infection
German measles
difficult delivery
cesarean delivery
complications
none
feeding problems
sleep problems
toilet training problems
emotional stress
bleeding
birth weight lbs oz.
alcohol use
drug use
cigarette use
other
Childhood health
chickenpox
normal delivery
(age )
German measles
(age )
red measles
(age )
rheumatic fever
(age )
whooping cough
(age )
scarlet fever
(age )
lead poisoning
(age )
mumps
(age )
diphtheria
(age )
poliomyelitis
(age )
pneumonia
(age )
tuberculosis
(age )
Name: Judy Sample

1/26/2016
autism
ID: 1
Page #: 5
SSN: 555-55-5555
ear infections
Birthday: 7/7/1946
mental retardation
asthma
allergies to
significant injuries
chronic, serious health problems
Delayed developmental milestones

sitting
controlling bowels
rolling over
standing
walking
feeding self
speaking words
speaking sentences
controlling bladder
sleeping alone
dressing self
engaging peers
tolerating separation
playing cooperatively
riding tricycle
riding bicycle
other
Emotional / behavior problems

None
drug use
alcohol abuse
chronic lying
stealing
violent temper
fire-setting
hyperactive
animal cruelty
assaults others
repeats words of others

not trustworthy
hostile/angry mood
indecisive
immature
bizarre behavior
self-injurious threats
frequently tearful
distrustful
extreme worrier
self-injurious acts
impulsive
easily distracted
poor concentration
often sad
breaks things in anger
lack of attachment
disobedient
other
Social interaction
normal social interaction
isolates self
very shy
inappropriate sex play

dominates others
associates with acting-out peers
alienates self
other
Intellectual / academic functioning

normal intelligence
high intelligence
learning problems
authority conflicts
attention problems
Current or highest education level

Describe any other developmental problems or issues
Socio-Economic History
underachieving
mild retardation
moderate retardation
severe retardation
Date:
Name: Judy Sample

1/26/2016
Living situation
housing adequate
homeless
housing overcrowded
dependent on others for housing
housing dangerous/deteriorating
ID: 1
SSN: 555-55-5555
Page #: 6
Social support system
Military
supportive
network
never in military
few friends
substance-use-based friends
Birthday: 7/7/1946
Date:
served in military - no incident

served in military - with incident
no friends
distant from family of origin
living companions dysfunctional
Employment
employed and satisfied
Financial situation
no current financial problems
Legal history
no legal problems
employed but dissatisfied

unemployed
coworker conflicts
supervisor conflicts
large indebtedness
poverty or below-poverty income
impulsive spending
relationship conflicts over finances
unstable work history

disabled:
now on parole/probation
arrest(s) not substance-related
arrest(s) substance-related
court ordered this treatment
jail/prison time(s)
total time served:
Describe last legal difficulty
Sexual history
heterosexual orientation
Cultural/spiritual/recreational history
cultural identity (e.g., ethnicity, religion)
homosexual orientation
bisexual orientation
Describe any cultural issues that contribute to current problem and/or should be
taken into account during treatment planning
currently sexually active

currently sexually satisfied
currently sexually dissatisfied

age first sex experience
age first pregnancy/fatherhood
history of promiscuity age to
history of unsafe sex age to
currently active in community/recreational activities?

formerly active in community/recreational activities?
currently engage in hobbies?
currently participate in spiritual activities?
If answered "yes" to any of above, describe
Additional information
Sources of Data Provided Above

Patient self-report for all
A variety of sources
Presenting Problems/Symptoms
patient self-report
Family History
patient self-report
Developmental History
patient self-report
patients parent/guardian
other
Emotional/Psychiatric History
patient self-report
other
Medical/Substance Use History

patient self-report
other
Socioeconomic History
patient self-report
Name: Judy Sample

1/26/2016
other
ID: 1
SSN: 555-55-5555
Page #: 7
other
Birthday: 7/7/1946
other
Date:

Biopsychosocial History: Presenting Problems

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Name: Judy Sample

Current Symptom Checklist (Rate intensity of symptoms currently present)

Prior outpatient psychotherapy?

Has any family member had outpatient psychotherapy?

Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?

Prior or current psychotropic medication usage? If yes:

Name: Judy Sample

Parents' current marital status

Describe childhood family experience

separated for years

normal home environment

mother involved with someone

Age of emancipation from home:

Special circumstances in childhood

List all persons currently living in patient's household

List biological / adopted children not living in same household as patient

Frequency of visitation of above:

List name of primary care physician

Name: Judy Sample

List name of psychiatrist (if any):

Is there a history of any of the following in the family

high blood pressure

other chronic or serious health problems

Describe any serious hospitalization or accidents

List any abnormal lab test results

Substance Use History

Substance use status

early full remission

early partial remission

sustained full remission

sustained partial remission

Patient Treatment history

Name: Judy Sample

First use age

Last use age

Consequences of substance abuse

birth weight lbs oz.

Name: Judy Sample

Delayed developmental milestones

Emotional / behavior problems

repeats words of others

inappropriate sex play

Intellectual / academic functioning

Current or highest education level

Name: Judy Sample

served in military - no incident

living companions dysfunctional

employed but dissatisfied

unstable work history

Describe last legal difficulty

currently sexually active

currently sexually dissatisfied

currently active in community/recreational activities?

If answered "yes" to any of above, describe

Sources of Data Provided Above

Medical/Substance Use History

Name: Judy Sample

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