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Name: ____________________________ age: ____________ Date of admission: ____________________
Legal Admission Status: ______ Date of encounter: _________________ patient was seen and examined, 
 

Write psychatric interview a patient with depression. it must have subective to obexctive compnent with MSE, diagnose, case formulation and plan. 

 

 

chart reviewed and case discussed with clinical staff available at time of visit. Additional informants: 
CHIEF COMPLAINT/REASON FOR ADMISSION: __________________________________________
________________________________________________________________________________________
HISTORY OF PRESENT ILLNESS: ________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PAST PSYCHIATRIC HISTORY/PREVIOUS PSYCHIATRIC VISITS __________________________
________________________________________________________________________________________
________________________________________________________________________________________
COLLATORAL INFORMANTS: ___________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PAST MEDICAL HISTORY: ______________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PAST SURGICAL HISTORY: _____________________________________________________________

 

 

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CURRENT MEDICATIONS (INCLUDING COMPLIANCE): __________________________________
________________________________________________________________________________________
________________________________________________________________________________________
ALLERGIES: ___________________________________________________________________________
PSYCHOSOCIAL HISTORY: Marital status: ___________ Lives with: ______________ Children:______
Sexual Orientation/Gender Identity: ___________________________________________________________ 
(NOTE: If LGBT, elicit “out” status, family dynamics): ___________________________________________ 
Education: _______________________ Occupation: ______________________ Legal History: __________
History of physical/emotional/sexual abuse, history of bullying: _________Religion: ________ 
Military Service: ____________
FAMILY HISTORY OF PSYCHIATRIC ILLNESS:___________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
History of Family Suicide Attempts/Completed Suicides: _______________________________________
SUBSTANCE ABUSE HISTORY: 
Smoker: ________________________________________________________________________________ 
History of Alcohol use/abuse: ________________________________________________________________ 
Days/Week:______________ Number of Drinks consumed/episode: _________________________________
Drug Use/Abuse:__________________________________________________________________________ 
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
MENTAL STATUS EXAMINATION
GENERAL WELL BEING:
-Patient reports that (she/he) is sleeping (well, poorly, fair). States that (she/he) has trouble (falling asleep, 
staying asleep, waking up feeling as if she/he had not slept at all).

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
DNP 650

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