Anxiety [] no symptoms - Rates as /10.

[] ≥6 months
[] Worry
[] Anxiety
[] Tension in muscles
[] Concentration deficit
[] Hyperarousal/irritability
[] Energy loss/fatigue
[] Restlessness
[] Sleep disturbances
[] Panic Attacks
[] Physical symptoms ___________

OCD:
[] Recurrent, persistent thoughts/images
[] Repetitive behavior

Comments:

Depression [] no symptoms - Rates as /10.

[] ≥2 weeks
[] Depressed mood
[] Sleep ↑or↓
[] Interest/pleasure ↓ (anhedonia)
[] Guilt/feelings of worthlessness
[] Energy↓/fatigue
[] Concentration deficit
[] Appetite/weight ↑or↓
[] Psychomotor ↑or↓

Comments:

Mania [] no symptoms
[] ≥ 1 week
[] Elevated, expansive, irritable mood
[] Distractible-attn to irrelevant stimuli
[] Insomnia
[] Impulsive Behavior
[] Grandiosity
[] Flight of ideas/racing thoughts
[] Activity ↑goal directed
[] Agitation
[] Speech (pressured)
[] Thoughtlessness

Comments:

Psychosis [] no symptoms

[] ≥1 month
[] Delusions
() Paranoid
() Ideas of reference
() Control
() Grandeur
() Guilt
() Somatic
[] Hallucinations (A/V/O/T)
[] Disorganized speech
[] Disorganized behavior
[] Negative symptoms:
() aPathy/avolition
() aLogia
() Affective flattening
() aNhedonia/asociality
() aTtention deficit

Comments:

PTSD [] no symptoms

Trauma Unable to function

[] Physical abuse [] Dissociative amnesia
[] Sexual abuse [] Anhedonia
[] Elder abuse [] Negative feelings (guilt, horror, fear)
[] Adult molested as a child
[] Robbery victim
[] Assault victim
[] Dating violence
[] Domestic Violence
[] Human trafficking
[] Survivor of homicide
[] Rape victim
[] Victim of stalker
[] Car accident
[] Other

Reexperience
[] Intrusive thoughts/images Month or more
[] Nightmares [] ≥1 month
[] Flashbacks

Arousal increased
[] Triggers- psych distress [] hypervigilance
[] Triggers- physical reaction [] insomnia

Avoidance [] irritability/anger outbursts

[] Thoughts/conversation [] ↓concentration
[] Activities/places [] ↑vigilance
[] Memories [] startle

Comments:

ADD/ADHD SYMPTOMS REPORTED [] no symptoms

Inattention symptoms
[] Low attention to details or careless mistakes
[] Difficulty sustaining attention in task or play
[] Does not seem to listen or mind wanders when being spoken to directly
[] Does not follow through, fails to finish tasks/activities
 [] Poor organization / fails to meet deadlines
[] Avoid or reluctant to engage in task requiring mental effort
[] Loses things
[] Easily distracted
[] Forgetful

[]/9 Inattentive symptoms (6 needed for under 17, 5 needed for over 17 for a continuous 6 month
period)

Hyperactivity and impulsivity

[] Fidgets
[] Leaves seat
[] Runs or climbs in inappropriate times (in adults may be feeling restless)
[] Unable to play or engage in leisure activities quietly
[] On the go / driven by a motor
[] Talks excessively
[] Blurts answers / can't wait for turn in conversation
[] Difficulty waiting his/her turn
[] Interrupts or intrudes on others

[]/9 hyperactive/impulsive symptoms (6 needed for under 17, 5 needed for over 17 for a
continuous 6 month period)

Comments:

Suicide: [] denies [] ideation [] gesture [] plan [] forward thinking Homicide: []

denies [] ideation [] gesture [] plan

Comments:
Previous suicide attempts:
[] Yes:
[] No:

Access to lethal means:

[] Yes:
[] No:

Substance Use: (first use, heaviest use, length, stop attempts, most recent use)

[] Denies history of substance use

Cannabis: [] Yes [] No Comments:

Tobacco: [] Yes [] No Comments:

Cocaine/Amphetamines: [] Yes [] No Comments:

Heroin: [] Yes [] No Comments:

Ecstasy: [] Yes [] No Comments:

LSD: [] Yes [] No Comments:

Inhalants: [] Yes [] No Comments:

Rx Drugs (e.g. Benzos/pain pills):[] Yes [] No Comments:

Caffeine: [] Yes [] No Comments:

MAT: (medication assisted treatment)

[] Yes
[] No

Comments:

EtOH:

[] Denies history of EtOH use

Initial Screen [] Yes [] No (Complete CAGE Assessment if yes)

Cut down (have you ever felt you should cut down) [] Yes [] No Comments:

Annoyed (have people annoyed you by criticizing your drinking?) [] Yes [] No Comments:

Guilty (have you ever felt bad or guilty about your drinking?) [] Yes [] No Comments:

Eye-opener (have you ever needed a drink first thing in the morning?) [] Yes [] No Comments:

Comments:

First use:
Heaviest use:
Duration:
Stop attempts:
Most recent use:

MAT: (medication assisted treatment)

[] Yes
[] No

Comments:

Nutrition concerns:

[] Yes
[] No

Weight Height Appetite [] Good [] Fair [] Poor [] Breakfast [] Lunch [] Dinner []

Snack(s)

Purge: []Yes []No

Restrict: []Yes []No
Overeat: []Yes []No
Binge: []Yes []No
Hoarding: []Yes []No

Comments:

Sleep concerns:
[] Yes
[] No

Duration: hours/night.

Insomnia: []Yes []No

Fragmented: []Yes []No
Rumination: []Yes []No
Nightmares/Vivid dreams: []Yes []No

Sleep Apnea: []Yes []No

BiPAP []Yes []No CPAP []Yes []No

Comments: