What is an example of a psychiatric evaluation template?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Answer

Name:

Date of Evaluation:

DOB:

Age:

Race: A B H W O

Sex: M F Height: Weight:

Referred by:

CC:

History of Present Illness:

Interest:

Weight:

Concentration:

Guilt:

Energy:

Medication/s:

Allergies:

Past Medical History:

Head Trauma:

Seizure:

Past Surgical History:

Past Psychiatric History:

Family History:

Social History:

Marital Status:

Employment:

Children:

Legal:

Abuse:

Education:

Other:

Patient Assets:

Mental Status Examination

General:

Attire:

Eye Contact:

Grooming/Hygiene:

Facial Expression:

Motor Activity:

Cooperative:

Speech:

Mood: " "

Affect:

Hallucinations:

Delusion(s):

Suicidal Ideation:

Homicidal Ideation:

Alert and Oriented: Person Place Situation MM/DD/YY

President:

Apple/Orange:

World/dlroW 20–3 = " "

Bird in Hand:" "

Insight:

Judgment:

Memory:

Estimated IQ:

Reliability

Impulse Control:

Diagnostic Impressions

A summary of the most pertinent features of the examination may be provided, offering the clinicians opinion and impressions about the most likely or relevant diagnoses, should any be present.

Initial Treatment Plan

Medication – Risk/Benefits/Side Effects/Alternatives Discussed/Informed Consent Obtained for:

Therapy:

Primary Care Physician – Routine Health Maintenance – Annual Physical Examination Laboratory Test.

Education and Instruction Given to Patient.

If condition changes go to the nearest Emergency Room.

Return to clinic/referral:

Other:

Patient verbally acknowledged understanding and agreed with the afore mentioned treatment plan.

Signature/date


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