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Initial psychiatric screening.
Legal Status
Baker Act | Marchman Act | Ex-Parte | Voluntary |
Initiated by: Judge | Police | Provider | Other |
If police, specify department: |
Mental Status Exam
Appearance | Appropriate | Disheviled | Other |
Mood | Appropriate | Angry | Sad | Manic | Other |
Affect | Appropriate | Flat | Restricted Other |
Motor Behavior | No Abnormalities Catatonic |
Speech | Unremarkable Pressured Hesitant |
Thought Process | Coherent Incoherent |
Judgement/Insight | Adequate Fair Poor |
AVH/Delusions | Present Not Present Other |
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Presenting Problem
Symptoms |
History |
Suicidal Threat/Attempt | Homicidal Threat/Attempt | Self-Inflicted Injury | Traumatic Event | Legal Court Order | Physician Order | Impulsive/Dangerous BehaviorPsychotic Features | Cognitive |
Psychiatric Treatment/Hospitalization | ECT | Substance Abuse Treatment | No Previous Treatment |
Living Status
Marital Status |
Current Living Arrangement |
Single |
House/Apartment/Homeless |
Married |
SNF or ALF? |
Divorced |
Lives with: |
Other: |
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Substance Use
Active Abuse | Past History | No History |
Substance: |
Active | Early Remission | Sustained Remission |
Route: |
Frequency: |
History of Abuse/Trauma
Yes |
Physical | Sexual | Emotional |
| |
Traumatic event: |
No |
Sleep
Symptoms |
Promotion |
Difficulty Falling Asleep |
Relaxation Techniques |
Difficulty Staying Asleep |
Avoid Naps |
Nightmares |
Avoid Stimulants |
Napping |
Ear Plugs/Face Mask |
Other: |
Other: |
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Nutrition
History of Eating Disorder Yes | No |
Weight Change in Last 3 Months Yes | No |
Weight Change in Last 6 Months Yes | No |
Intentional Weight Change Yes | No |
Appetite Increased Yes | No |
Appetite Decreased Yes | No |
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Created By
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