Initial Diagnostic Mental Health History and Checklist
Initial Mental Health History and Symptom-Problem Checklist Screen
Name:___________________________________________________________Age ______DOB ____________Date_________
Referred by:________________________School/Work:_______________________________________HighestGrade__________
Address: _____________________________________________________________________________Tele #_____________
Family of Origin:
Biological Father’s name:_________________________ Age :_________Education: _______Employment___________________
Biological Mother’s name:____________________________Age:______Education:_______Employment___________________
If a child , is child adopted? Yes No If yes, age when adopted ______Is child in special education, what kind?______________
Are parents married? yes no Separated ? yes no Divorced? yes no Other? Like a foster family etc;____________________
If other circumstances apply please explain:_______________________________________________________________________
_____________________________________________________________________________________________________
Present Family: List people in family and their relationship to the patient.
Name Relationship Age Name Relationship Age
1.___________________________________________ 2.____________________________________________
3.___________________________________________ 4.___________________________________________
5.____________________________________________ 6._______________________________________
List the three main problems you would like addressed in order of importance.
1._____________________________________________________________________________________________________________________
2._____________________________________________________________________________________________________________________
3._____________________________________________________________________________________________________________________
Where do they cause the most problems? at [ ] home, [ ] school, [ ]work, [ ]family, [ ]Other___________________
How you would like them helped? [ ] medication, [ ] therapy, [ ] just a Diagnosis Other-Explain_________________
_____________________________________________________________________________________________________
List Present and Past Medical Problems & Medications, Who’s the treating M.D.? Surgeries ? Serious accidents? Head Trauma?
Problems with pregnancy, labor, delivery of patient? What was birth weight? Was mom on any medications, drugs or alcohol during pregnancy?
List all bad drug reactions, side effects, food & drug allergies: Are there present Drug & Alcohol problems? Tobacco? Yes[ ], No[ ]
List all Present Psychiatric Medications, How are they helpful? Are they causing other problems or having negative effects?
List all Past Psychiatric Medications that have been tried, with good and bad effects they may have caused:
List all Other Past Mental Health Treatments and what problems they addressed, such as Hospitalizations, Partial Hospitalization, Drug & Alcohol, School/Home Based Therapy, Individual/Family counseling? Legal Problems Yes[ ], No[ ] Victim of Abuse-Neglect Yes[ ], No[ ] Please explain.
Please use the questions below as a guide in writing a brief summary of the history of problems you want help with.
Did they come out of the blue?
Yes [ ] No [ ]
Were they always there in
some form or another? Yes [ ] No [ ]
Related to any new or old stresses?
Yes[ ], No[ ], If yes explain:
Do they come and go?
Yes[ ], No[ ], If yes explain:
What has made them better?
What has made them worse?
Any physical problems esp. those
that come go like headaches, that
may be caused by these problems?
Explain if anybody else in the family
has or had similar problems?
Family Psychiatric History-List All Psychiatric Medications Close & Distant Relatives Have Been On and Good and Bad Effects:
List family members psychiatrically hospitalized, in a Drug or Alcohol Rehab, in jail or prison, and for what reason?
DIRECTIONS: 1. CHECK AFTER THE NUMBER IF THAT LIST SEEM TO APPLY GENERALLY
2. THEN CIRCLE AN ITEM OR ITEMS IF THEY MORE MOST SPECIFICALLY APPLY
Attention-Impulsivity Cluster:
1. [ ] Always moving, on the go, into everything, frigidity, can’t be or sit still, even when sleeping
2. [ ] Can’t pay attention, focus on boring stuff for 15 minutes when left alone, easily distracted
3. [ ] Doesn’t slow down, to stop and think or, to focus on consequences before talking or doing
4. [ ] Difficulty organizing tasks and activities, looses things, is forgetful, seems not to listen
5. [ ] Seems not learn from making mistakes and from life experiences, difficult to discipline
6. [ ] Excitable, with no mood swings, short fuse, but is able to calm self down, in a reasonably short time
Temperament-Developmental Cluster:
7. [ ] Persistent preoccupation with parts of objects, insistence on doing things over and over
8. [ ] Repetitive body movements like, clapping, finger flicking, rocking, walking on tip toes,
9. [ ] Too sensitive to changes in routine, or surroundings, causing tearfulness, worry, panic, anger, rage
10. [ ] Colic as infant, fussy, needy, easily upset, hard to please, soothe, calm, whinny irritable person
11. [ ] Sensitivities to sound, touch, light, taste, smells, textures of things like clothing & foods
12. [ ] Hard to please as a child, slow to warm up, with unpredictable emotional responses
13. [ ] Neither desires or enjoys close relationships, indifferent to praise or criticism,
14. [ ] Likes to be alone doing solitary activities, only close relationship are in family
Unstable Mood Cluster:
15. [ ] Often unpleasant, irritable, nasty, mean, excitable, defiant to authorities, bullies peers
16. [ ] Short fuse, easily made angry, can’t calm self down in 20 min, rages lasting from minutes to hours
17. [ ] Quick and frequent mood swings, ups and downs of feeling states, Dr Jeckle & Mr. Hyde
18. [ ] Too demanding & demands must be met immediately, difficult to live with, walking on eggshells
19. [ ] Can’t control anger, aggressive, violent, destructive to property, physically hurts others
20. [ ] Injures self on purpose, self mutilates, bangs head, bites self, punches walls
21. [ ] Brief periods of sadness, irritable and whinny, cries over small annoyances and hurts
22. [ ] Talks too much, too fast, difficult to follow, goes off on tangents , talks in circles
23. [ ] Needs little sleep but not tired next , often unable to sleep because mind won’t shut down
24. [ ] Excessive involvement in pleasurable activities, that have high potential for painful consequences
25. [ ] Too happy, cheerful, enthusiastic, silly, giddy, goofy, overly friendly, even with strange
26. [ ] Mostly high energy states with increase of goal directed activities at home, work, school socially
27. [ ] Thinks too highly of self, over values abilities, sets unrealistic goals, bossy, needs to be in charge
28. [ ] Low energy states increase with age, may occur with physical illnesses like headaches, GI problems
29. [ ] Hyperactive, high energy states correlates strongly with mood and motivation
30. [ ] Impulsive -not thinking of consequences of behavior, speech, goals, plans, and relationships
31. [ ] Distracted by minor and unimportant things, and changes excessively driven by mood
Depression Cluster:
32. [ ] Depression- sad mood, tearful, whiney, easily cries, irritable, feels empty and alone
33. [ ] Interest- diminished pleasure and interest in most things, don’t care, too bored attitude
34. [ ] Body Weight- significant weight loss or gaining, eating too much or too little, not dieting
35. [ ] Sleep- sleeping too much, too little, waking up cant fall back to sleep, never feels rested
36. [ ] Mind/Body Energy- as observed by others either too slowed down or speeded up
37. [ ] Fatigue- loss of energy, always tired, fatigued, no motivation, drive, ambition
38. [ ] Negativity- worthless, guilty, ashamed, negative about self, present , past and future
39. [ ] Concentration- diminished ability to think, remember, concentrate, mind goes blank
40. [ ] Hopelessness- hopeless , recurrent thoughts of death, dying, suicide ideas, attempt, plan
Anxiety cluster:
41. [ ] Social Anxiety- Fear , embarrassment of social, performance situation, with unfamiliar people scrutinizing
42. [ ] Obsessive-Compulsive [OCD]- Worry of not doing rituals, hand washing, checking, ordering, counting, repeating, praying
43. [ ] Panic- attacks of anxiety, heart pounds, shaking, short of breath, dizzy, lightheaded, losing control fear
44. [ ] Post Traumatic Stress Disorders [PTSD]- Extreme fear, numbing, avoidance and re-experiencing trauma, abuse, neglect, catastrophes
45. [ ] Separation Anxiety -Worry over losing & leaving loved one, trouble being & sleeping alone, need some to go places
46. [ ] School/Work dysfunction due to any Anxiety Disorders-Frequent school work lateness, avoidance, absences, due to illness, especially early in week
47. [ ] Physical problems like Chronic Fatigue, some Fibromyalgia caused by Anxiety- Always sick, headaches, migraines, stomach-bowel problems, easily fatigued, allergic, rashes
48. [ ] Generalized Anxiety Disorder -Too worried all the time , keyed up, on edge, tense, irritable, trouble falling and staying asleep
Thinking Cluster:
49. [ ] Speech is odd, peculiar, too vague, too complex, to specific, speaks in riddles
50. [ ] Thinking is illogical, thoughts are disconnected, disorganized, hard to follow
51. [ ] Speech is too pressured, too fast, too much, too emotionally charged, never seems to end
52. [ ] Person speech goes off on tangents, talks in circles, gets off track, changes subjects frequently
53. [ ] Speaks too little, seems to be struggling to put feeling and thoughts into words, hardly talks at all
Reality Testing Cluster:
54. [ ] At times too tuned in to fantasy, their self, too much into their own world, rather than others
55. [ ] Unaware of time, place, who you are, dazed, lost in time, confused, acting and feeling like in a dream
56. [ ] Reads hidden insulting or threatening meanings into everyday remarks and events
57. [ ] Holds grudges, unforgiving of insults, injuries or slights
58. [ ] Suspects without sufficient basis that others are out to use, abuse, harm or deceive
59. [ ]Thoughts so loud seem like voices, hearing and seeing things not sure if they are there and real
60. [ ] Senses, feels , perceives, sees, hears, tastes, smells, things that others aren’t aware of
Relatedness Cluster:
61. [ ] Difficult to read as if there is an emotional barrier between the person and others
62. [ ] Poor eye contact, facial expressions, body postures, gestures to communicate feelings
63. [ ] Relatedness, behavior, appearance is odd, peculiar, slightly off, unusual, something not just right
64. [ ] Responds and relates in shallow, detached manner with restricted flattened emotions
65. [ ] Poor verbal/non verbal give and take in sharing , understanding, and seeking emotional responses
Movement-Impulse Cluster:
66. [ ] Simple Motor Tics- rapid meaningless muscle contraction of few muscles like eye blinking
67. [ ] Simple Vocal Tics - sniffs, snorts, clicks, throat clearing, grunts, coughs, barks, yelps, giggle
68. [ ] Complex Motor- touching, squatting, twirling & retracing steps when walking, repeating
69. [ ] Complex Vocal- saying and repeating words, phrases, part of songs
70. [ ] Motor Driven Compulsions- doing things over and over, rituals driven by tics
71. [ ] Motor Driven “ADHD type symptoms”- over active, impulsive, inattention driven by tics
Conduct-Antisocial Cluster:
72. [ ] Shallow affection, love, joy, Lack of appropriate guilt, shame, remorse, sympathy, compassion
73. [ ] Routinely ignores moral standards, social norms, being deceitful, breaking rules, lying, stealing
74. [ ] Emotionally tuned in, sensitive, giving, caring, alternating with cold, aloof, distant, selfish
75. [ ] Trouble with the law, truancy, delinquency, arrests, probation, parole violations, violent crimes
Other
76. [ ] Stuttering, stammering, words get stuck, can’t speak fluently, trouble pronouncing words
77. [ ] Over use of drugs, alcohol, tobacco, exercise, food, TV, video games, excessive daydreaming
78. [ ] Trouble in reading, spelling, math, speech, requiring special intervention
79. [ ] Hand writing is poor, problems with fine or gross motor co ordination, clumsy, accident prone and other “soft neurological” symptoms [like minor issues with auditory-visual and other sensory processing]
80. [ ] Bed wetting, deep sleeper, hard to wake up , nightmares, night terrors, sleep walking
Atypical Cluster: “Atypical-ness” a proposed cluster:
For the “Atypical Child/Person” who doesn't fit into any of the above clusters or categories and yet have symptoms from more than one, often from many clusters. Because these people have uneven development their symptoms-problems may come and go. These people have unique and unpredictable responses to treatment with medications and with non biological modalities. Because people in this cluster are often "force fitted" into another cluster or diagnoistic group, the expected treatment response doesn't occur, or works for a while and then either stops or makes matters worse. More than in any other group whatever medication is chosen one must start very low, and go very slow because of brain chemistry sensitivity and its unpredictableness . Be prepared for unusual and unpredictable good and bad effects even at very small doses. “Micro dosing” using very small doses of two or more medications can be tried to get the desirable effects.
Some of the symptoms-problems seen in this proposed “Atypical” group are:
1) [ ]Uneven development as infant-child, loosing & gaining functions unpredictably like speech and language
2) [ ]Transitions cause panic anxiety or rage attacks, physical symptoms like hives, irritable bowel, headaches
3) [ ] Unusual sensitivities to touch, taste, positioning, sound, lights.
4) [ ] Poor eye contact, and poor non verbal communication using gestures, body language
5) [ ] Not getting social rules, and cues from other, not getting the point of jokes or riddles or social moves
6) [ ] Socially stiff, and awkward, verbally and non verbally, marches to his or her own drummer
7) [ ] Unusual or peculiar relatedness, but not overtly strange or bizarre, slightly off emotionally
8) [ ] Something just “not right” about how they relate, respond, react to people, even those they know well
9) [ ] Get stuck in doing something, and has to finish it, and if not panic, gets angry, or too upset
10) [ ] Unusually high and over developed abilities in some areas of usually in the area of the thinking and doing mind, with unusually low function if not actual deficits in other area especially those related to the experiencing-relationship-feeling mode of the mind.
For evaluators use- don’t write below this line.__________________________________________________
Summary:
Axis I
Axis II
Axis III
Axis IV
Axis V
Rx:
RTC: