Biopsychosocial History

Name
_________________
Patient ID
_______
__
Patient SSN
___________
Date
_________
Date of Birth _
__
_______
Page
1
Biopsychosocial History
Presenting Problems
Primary
_____________________________________________________________________________________________
______
Secondary
_____________________________________________________________________________________________
______
_____________________________________________________________________________________________
______
Current Symptom Checklist
(Rate intensity of symptoms
currently present)
Mild
= Impacts quality of life, but no significant impairment of day

to

day functioning
Moderate
= Significant impact on quality of life and/or day

to

day functioning
Severe
= Profound impact on quality of life and/or day

to

day functioning
Symptom
Impact
Symptom
Impact
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Aggressive Behaviors

Laxative/Diuretic
Abuse

Agitation

Loose Associations

Anorexia

Mood Swings

Appetite Disturbance

Obsessions/Compulsions

Bingeing/Purging

Oppositional Behavior

Circumstantial Symptoms

Panic Attacks

Concomitant Medical Condition

Paranoid Ideation

Conduct Problems

Phobias

Delusions

Physical Trauma Perpetrator

Depressed Mood

Physical Trauma Victim

Dissociative States

Poor Concentration

Elevated Mood

Poor Grooming

Elimination Disturbance

Psychomotor Retardation

Emotional Trauma Perpetrator

Self

Mutilation

Emotional Trauma Victim

Sexual Dysfunction

Emotionality

Sexual Trauma
Perpetrator

Fatigue/Low Energy

Sexual Trauma Victim

Generalized Anxiety

Significant Weight Gain/Loss

Grief

Sleep Disturbance

Guilt

Social Isolation

Hallucinations

Somatic
Complaints

Hopelessness

Substance Abuse

Hyperactivity

Worthlessness

Irritability

Other

Name
_________________
Patient ID
_______
__
Patient SSN
___________
Date
_________
Date of Birth _
__
_______
Page
2
Emotional/Psychiatric History

No

Yes
Prior
out
patient psychotherapy
If yes, on
occasions. Longest treatment by
for
sessions from
/
to
/
Provider Name
Month/Year
Month/Year
Prior provider name
City
State
Diagnosis
Intervention/Modality
Beneficial
____________________
___________
____
________________
___________________
__________
____________________
___________
____
________________
___________________
__________

No

Yes
Has any family member had outpatient psychotherapy
If yes, who/why (list all):
_____________________________________________________________________________________
___________
________________
_________________________________________________________________________________________________________
_______

No

Yes
Prior
in
patient
treatment for a psychiatric, emotional, or substance use disorder
If yes, on
occasions. Longest treatment
at
____________
from
/
to
/
Name of facility
Month/Year
Month/Year
Inpatient facility name
City
State
Diagnosis
Intervention/Modality
Beneficial
____________________
___________
____
________________
___________________
___________
____________________
___________
____
________________
___________________
___________

No

Yes
Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder
If yes,
who/why (list
all):
___________________________________________________________________________________________________________
___
______________________________________________________________________________________________________________

No

Yes
Prior or current psychotropic medication usage
If yes:
Medication
Dosage
Frequency
Start
Date
End
Date
Physician
____________________
___________
____
_____
___________
_____________
___________________
_________
_
____________________
___________
____
_____
___________
_____________
___________________
_________
_

No

Yes
Has any family member used psychotropic medications
If yes, who/what/why (list all):
_____________________________________________________________________________________________________________________
____________________________________________________
_________________________________________________________________

 
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