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Psychiatric Evaluation Patient Name DOB MRN

Review of Systems Chief complaint/Reason for consult Start Time Stop Time Date
Review of Systems Yes No
Constitution
Fatigue or Malaise  
Fever or chills   History of Present Illness ‰Patient is Nonverbal. History obtained from ‰Family ‰Medical records
Appetite changes  
Eyes Suicidal ideation ‰Yes ‰No Plan formed ‰Yes ‰No Patient has the means to carry out the plan ‰Yes ‰No
Conjunctivitis   Homicidal ideation ‰Yes ‰No Plan formed ‰Yes ‰No Patient has the means to carry out the plan ‰Yes ‰No
Eye pain
Vision changes
ENT/mouth
Sore throat
Epistaxis
Rhinorrhea
Respiratory
Dyspnea
Cough
Wheeze
Cardiovascular
Chest pain
Ankle edema
Palpitations
Gastrointestinal
Nausea or vomiting
Weight changes Allergies and Medications
Abdominal pain
‰Medications reviewed ‰Medications reconciled with Nursing Home or Hospital data
Genitourinary
Hematuria
Dysuria
‰Allergy List reviewed ‰No drug allergies ‰No food allergies ‰History of life threatening allergic response to
Urethral discharge

Musculoskeletal
Myalgias Past Medical History, Social History and Family History
Arthralgias ‰Yes ‰No Arrhythmias ‰Yes ‰No HIV/AIDS ‰Yes ‰No Thyroid disease
Joint swelling ‰Yes ‰No Asthma ‰Yes ‰No Kidney disease ‰Yes ‰No Tuberculosis
Skin/Breasts ‰Yes ‰No Coronary Artery Disease ‰Yes ‰No Liver disease ‰Yes ‰No Malignancy
Masses
New skin lesions
‰Yes ‰No COPD ‰Yes ‰No Porphyria
Rash
‰Yes ‰No Diabetes ‰Yes ‰No Seizures ‰Yes ‰No Neuroleptic Malignant Syndrome
Neurologic ‰Yes ‰No Heart Failure ‰Yes ‰No Syphilis ‰Yes ‰No Malignant Hyperthermia
Headaches
Seizures Past Surgical History
Paresthesias
Endocrinologic 
Hair loss Past Psychiatric History
Polydipsia ‰Yes ‰No Anxiety ‰Yes ‰No Hospitalizations for psychiatric illnesses
Tremors ‰Yes ‰No Bipolar disorder
Heme/Lymph ‰Yes ‰No Depression ‰Yes ‰No History of Electroconvulsive Shock Therapy 
Bleeding gums ‰Yes ‰No Mania
Unusual bruising ‰Yes ‰No Psychosis ‰Yes ‰No Prior Suicide attempts
Swollen lymph nodes
‰Yes ‰No Schizophrenia 
Allergy/Immunology
Nasal congestion
‰Yes ‰No Personality disorder
Psychiatric ‰Yes ‰No Other
Agitation Social History / Risk factors
Hallucinations ‰Denies ‰Yes Ever smoker ___ # Packs X ____ # Yrs ‰Denies ‰Yes Alcohol use ___ Drinks per ‰day ‰week
Depressed mood ‰Denies ‰Yes Chews tobacco ‰Denies ‰Yes Felt the need to cut down on drinking?
Insomnia ‰Denies ‰Yes Quit tobacco use Quit date _________ ‰Denies ‰Yes Annoyed by others criticizing drinking?
Hypersomnia      ‰Denies ‰Yes Guilt associated with drinking?
Altered concentration
‰Denies ‰Yes Feels safe at home or work ‰Denies ‰Yes Eye opener needed?
‰Denies ‰Yes Tattoos
Feels worthless
‰Denies ‰Yes High risk sexual behavior
Grandiose ideas
‰Denies ‰Yes Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible
Compulsions
‰Denies ‰Yes Prescription Drug dependence ‰Narcotics ‰Benzodiazepines
Believes they have
special powers
Family Medical History
New / increased
substance abuse ‰Asthma ‰CHF ‰COPD ‰Coronary Artery Dis ‰Pancreatitis ‰Peripheral Artery Disease ‰Renal Dysfunction
‰Thalassemia ‰Thrombotic disorder ‰Thyroid Disease ‰Malignancy ‰Other

‰Anxiety disorder ‰Bipolar disorder ‰Depression ‰Schizophrenia ‰Suicide or Suicide attempts

©MB and RR 2006-2010 e-medtools.com Revised 2Dec09 Health Care Provider Initials or Signature
Psychiatric Evaluation Patient Name DOB MRN
Exam To qualify as a comprehensive exam: Document every all of the bullets in Constitutional (including at least 3 vital signs) and the Psychiatric sections AND at least
one bullet in the Musculoskeletal section.
Vitals Constitutional (  3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam

Height _____ ‰in ‰cm x General Appearance ‰Well nourished ‰Cachectic ‰Obese
Grooming ‰Appropriate ‰Unkempt Deformities ‰None noted Present as follows
Weight _____ ‰lb ‰kg

Temperature _____ Musculoskeletal


x Strength & Muscle tone ‰Within normal limits ‰Increased ‰Decreased ‰Flaccid ‰Cogwheel ‰Atrophy
Pulse Rate _____ x Gait & Station ‰Within normal limits ‰Ataxia ‰Wide based gait ‰Shuffle
Rhythm ‰Regular ‰Irregular
Patient leans ‰Rt ‰Lt ‰Forward ‰Backward
Blood Pressure
Psychiatric
x Speech (Describe Rate, Volume, Articulation, Coherence, Spontaneity and include abnormalities)
________ ‰Sitting ‰Standing ‰Lying

________ ‰Sitting ‰Standing ‰Lying

Respiratory Rate _____


x Thought processes (Describe Rate, Content, Abstract reasoning and Computation)
Labs

\____/ ____ / ____ / ____ /


/ \ \ \ \
x Associations ‰Intact ‰Loose ‰Tangential ‰Circumstantial

Radiology
x Thoughts ‰Within normal limits ‰Illogical ‰Hallucinations ‰Obsessions ‰Preoccupation with violence
‰Homicidal ideation ‰Suicidal ideation

Additional Exam Findings x Judgment and Insight

Mental Status
x Orientation ‰Oriented to Person, Time, and Place NOT oriented to ‰Person ‰Time ‰Place

x Recent & Remote Memory

x Attention Span & Concentration

x Language

x Fund of Knowledge

x Mood & Affect ‰Within normal limits ‰Agitated ‰Anxious ‰Depressed ‰Hypomanic ‰Labile

©MB and RR 2006-2010 e-medtools.com Revised 2Dec09 Health Care Provider Initials or Signature
Psychiatric Evaluation Patient Name DOB MRN
Data Reviewed Impression
‰ER Notes
‰Labs Axis I
‰Radiology data
‰Pathology
‰ECHO and/or ECG Axis II
‰EEG
‰Pulmonary Function Test
Axis III
‰Nursing Notes/Vitals log
‰Primary Care Physician records
‰Psychiatry records Axis IV
‰Other past medical records
Care Coordinated with
‰Patient
‰HCPOA or Surrogate
‰Primary Care Physician
‰Consultant(s)
‰Case Management or Social Worker
‰Pharmacy
‰Nursing
Recommended Diagnostics
‰12-lead ECG
‰Echocardiogram
‰Computed Tomography
‰Magnetic Resonance Imaging

‰CBC with differential
‰PT, PTT, INR
‰Arterial Blood Gas
‰Basic Metabolic Panel (with calcium)
‰Complete Metabolic Panel
‰HIV
‰Hepatitis panel
‰Serum Porphyrin
‰RPR
‰TSH, T3, and Free T4 levels
‰Urinalysis

‰Toxicology panel
‰Blood alcohol level
‰Urinary catecholamines
Recommended Actions
‰Smoking cessation aids
‰Substance Abuse Counseling Physician Signature
cc
‰Antidepressant therapy
‰Antipsychotic therapy Code Status
‰Counseling Patient is currently ‰ABLE ‰UNABLE to understand their current health condition AND the consequences of
‰Other treatment options (including no treatment)

‰Pneumonia vaccine ‰FULL CODE ‰DO NOT ATTEMPT RESUSCITATION


‰Influenza vaccine 
‰ Patient has an advanced health care directive. HCPOA is _______________________________________

©MB and RR 2006-2010 e-medtools.com Revised 2Dec09 Health Care Provider Initials or Signature