12/17/23, 8:04 PM NR 548 psychiatric history assignment
Psychiatric History Assignment Template
S: Subjective
Information the client or representative told you
Initials: G.R Age: 25 Gender: female
Include vital signs if provided. State not provided here if not available: Not available
Allergies (and reaction)
Medication: None
Food: None
Environment: None
Chief Complaint (CC): “I think I might be depressed.” CC is a BRIEF statement identifying
why the client is here - in the patient’s
own words - for instance "I have been
History of Present Illness (HPI): feeling depressed," NOT "symptoms of
depression for 3 weeks.” History of
The client reports increasing depressive symptoms with onset five months ago. She is experiencing Present Illness (HPI)
stress related to unemployment and financial strain because she cannot afford the mortgage. She reports (1) develops illness narrative: (cogent
depressed mood, low energy, low motivation, hopelessness, and decreased appetite. She reports story with clear chronology, not a
difficulty falling and staying asleep due to worry, restlessness, and difficulty making decisions. She list of symptoms), and
endorses stress related to the above-mentioned stressors, as manifested by depressed mood and low (2) includes specific details of
motivation. She reports that her current mental state is impeding her ability to engage in hobbies she symptoms, and the impact of these
enjoys. symptoms on daily life.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. State NA if
no current medications.
Medication
Length of Time
(Rx, OTC, or Homeopathic) Dosage Frequency Reason for Use
Used
Tylenol 650mg PRN unknown Headaches
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, 12/17/23, 8:04 PM NR 548 psychiatric history assignment
Tylenol 650mg PRN unknown Headaches
Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include
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Psychiatric History Assignment Template
S: Subjective
Information the client or representative told you
Initials: G.R Age: 25 Gender: female
Include vital signs if provided. State not provided here if not available: Not available
Allergies (and reaction)
Medication: None
Food: None
Environment: None
Chief Complaint (CC): “I think I might be depressed.” CC is a BRIEF statement identifying
why the client is here - in the patient’s
own words - for instance "I have been
History of Present Illness (HPI): feeling depressed," NOT "symptoms of
depression for 3 weeks.” History of
The client reports increasing depressive symptoms with onset five months ago. She is experiencing Present Illness (HPI)
stress related to unemployment and financial strain because she cannot afford the mortgage. She reports (1) develops illness narrative: (cogent
depressed mood, low energy, low motivation, hopelessness, and decreased appetite. She reports story with clear chronology, not a
difficulty falling and staying asleep due to worry, restlessness, and difficulty making decisions. She list of symptoms), and
endorses stress related to the above-mentioned stressors, as manifested by depressed mood and low (2) includes specific details of
motivation. She reports that her current mental state is impeding her ability to engage in hobbies she symptoms, and the impact of these
enjoys. symptoms on daily life.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. State NA if
no current medications.
Medication
Length of Time
(Rx, OTC, or Homeopathic) Dosage Frequency Reason for Use
Used
Tylenol 650mg PRN unknown Headaches
about:blank 1/9
, 12/17/23, 8:04 PM NR 548 psychiatric history assignment
Tylenol 650mg PRN unknown Headaches
Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include
about:blank 2/9
