NR 548 Week 6 Psychiatric Interview Documentation Assignment Template (Initials; K. S)

Name: Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. to enter text. Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others. Diagnosed with depression 2000-2002. Bipolar disorder diagnosed 2007-2008 after a "break" with tough work circumstances as a military physician. Stable on current medications for years without recurrence of mood episodes. No history of suicide attempts. Client reports that he did encounter emotional and physical abuse during his childhood from his mother, unknown if treatment was involved during childhood. Previously wondered about possible ADHD (eval ~1998) but never formally diagnosed (Carlat, 2023). Comorbid mental disorders, depression symptom severity, and role impairment are common among Veterans initiating depression treatment through the Veterans Health Administration (Ziobrowski et al., 2021). Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed. Hypothyroidism - stable on levothyroxine. Patient reports his thyroid levels have been stable, with the last check being about a year ago. No other significant medical history was reported (Carlat, 2023). Family History (Fam Hx) - History includes but is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents (if information was provided), siblings, and children. Include grandchildren if pertinent. Name: ☐Fever/Chills Click or tap here to enter text. ☐Other: ☐Photophobia Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☒Trouble Sleeping Click or tap here to enter ☐Epistaxis Click or tap here to enter text. text. ☐Vertigo Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Other: ☐Other: Click or tap here to enter text. Click or tap here to enter text. Respiratory Neuro Cardiac MSK If patient denies all symptoms for this If patient denies all symptoms If patient denies all symptoms for this If patient denies all symptoms system, check here: ☐ for this system, check here: ☐ system, check here: ☐ for this system, check here: ☐ ☐Cough Click or tap here to ☐Syncope or ☐Chest pain Click or tap here to ☐Pain Click or tap here to enter text. Lightheadedness Click or tap enter text. enter text. ☐Hemoptysis Click or tap here to here to enter text. ☐SOB Click or tap here to enter text. ☐Limited ROM enter text.