Psychiatric Patient Interview Checklist Form
Complete this form to record structured information during a psychiatric patient interview.
Patient Full Name
*
First Name
Last Name
Date of Interview
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presenting Problem(s)
*
Mood disturbance
Anxiety
Psychosis
Substance use
Cognitive issues
Other
Duration of Presenting Problem(s)
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
Relevant Psychiatric History
*
No previous psychiatric history
Previous diagnosis
Previous hospitalization
Previous medication
Other
Current Medications
No current medications
Antidepressants
Antipsychotics
Mood stabilizers
Anxiolytics
Other
Mental Status Examination: Appearance & Behavior
*
Normal
Agitated
Withdrawn
Disheveled
Other
Mental Status Examination: Mood & Affect
*
Euthymic (normal)
Depressed
Elevated
Anxious
Labile
Other
Risk Assessment
*
No acute risk
Suicidal ideation
Homicidal ideation
Self-harm behavior
Other
Clinician's Notes / Impressions
Submit Checklist
Should be Empty: