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Psychological Evaluation Form

The document is a Psychological Evaluation Form designed to collect confidential personal, psychiatric, medical, and social history information from patients. It includes sections for presenting problems, psychiatric history, medical history, family history, developmental and social history, behavioral and emotional symptoms, and goals for assessment or treatment. The form concludes with a consent section for the patient to confirm the accuracy of the information provided.

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Shakthi
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5 views4 pages

Psychological Evaluation Form

The document is a Psychological Evaluation Form designed to collect confidential personal, psychiatric, medical, and social history information from patients. It includes sections for presenting problems, psychiatric history, medical history, family history, developmental and social history, behavioral and emotional symptoms, and goals for assessment or treatment. The form concludes with a consent section for the patient to confirm the accuracy of the information provided.

Uploaded by

Shakthi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Psychological Evaluation Form

All questions contained in this questionnaire are strictly confidential and will become part of the patient’s
medical record.
Date of Evaluation: _______________
Personal Information
• Full Name: __________________________________________________________________
• Date of Birth: _______________________________________________________________
• Age: _______________________________________________________________________
• Gender: ____________________________________________________________________
• Marital Status: ______________________________________________________________
• Contact Information:
o Phone: _________________________________________________________________
o Email: __________________________________________________________________
o Address: ________________________________________________________________
Referral Information
• Referred By: ________________________________________________________________
• Reason for Referral: _________________________________________________________
• Previously Seen by Another Doctor?
o □ Yes □ No
o If yes, provide details (e.g., name, specialty, reason): __________________________
_________________________________________________________________

Presenting Problem
• Describe your current difficulties or concerns: _________________________________
____________________________________________________________________________
• When did these problems begin?: ______________________________________
• Have they worsened, improved, or stayed the same?: _____________________
• What triggers or worsens the problems?: _______________________________
• What helps or relieves the problems?: __________________________________
Psychiatric History
• Have you ever been diagnosed with a mental health condition?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Have you received any psychiatric treatment in the past?
o □ Yes □ No
o If yes, list treatments (e.g., therapy, hospitalization): ______________________________

• Current Medications (Include dosages): _________________________________


_________________________________

• Past Medications (Include effectiveness): _________________________________


_________________________________

• Any previous suicide attempts or self-harm behaviors?


o □ Yes □ No
o If yes, explain: _____________________________________________
Medical History
• Do you have any chronic medical conditions?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Do you take any regular medications?
o □ Yes □ No
o If yes, list them: ___________________________________________
• Have you experienced head injuries, seizures, or other neurological issues?
o □ Yes □ No
o If yes, explain: _____________________________________________
• Date of last physical examination: ___________________________
• Allergies (medication, food, environmental):
o □ Yes □ No
o If yes, specify: ____________________________________________
• Surgical History (Include dates and types of surgeries):

• Do you use alcohol or recreational drugs?


o □ Yes □ No
o If yes, describe frequency and type: ___________________________
Family History
• Is there a family history of mental health conditions?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Family history of substance abuse?
o □ Yes □ No
o If yes, explain: _____________________________________________
• Any history of family conflicts or trauma?
o □ Yes □ No
o If yes, describe: ____________________________________________
Developmental and Social History
• Were there any developmental delays in childhood?
o □ Yes □ No
o If yes, specify: ____________________________________________
• Describe your relationships with family members: _________________________________

• Do you have close friends or a support network?


o □ Yes □ No
• Are you currently working or studying?
o □ Yes □ No
o If yes, specify occupation or course: _________________________
• Any major life events or trauma (past or recent)?

Behavioral and Emotional Symptoms


• Check all that apply:
o □ Depressed mood
o □ Anxiety or excessive worry
o □ Irritability or anger
o □ Sleep problems (too much or too little)
o □ Difficulty concentrating
o □ Low energy or fatigue
o □ Appetite changes (increase or decrease)
o □ Panic attacks
o □ Hallucinations or delusions
o □ Paranoia or suspiciousness
o □ Impulsive behaviors
o □ Self-harm thoughts or behaviors
o □ Suicidal thoughts
o □ Other: _____________________________________________
Goals for Assessment or Treatment
• What do you hope to achieve from this assessment or treatment?

Consent and Signature


I confirm that the information provided is accurate to the best of my knowledge.
Signature: _____________________________ Date: _______________
Clinician Notes (to be completed by assessor):

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