One Page MH History and Screen
Cyril M J Puhalla MD Board Certified Child, Adolescent and Adult Psychiatry
Name:___________________________________________________________Age ______DOB ____________Date_________
Referred by:________________________School/Work:_____________________HighestGrade_______Home Tele#__________
List all present medications and dosages: Who prescribes them?___________________________________________________________________
_______________________________________________________________________________________________________________________
List Present Medical Problems:______________________________________________________________________________________________________________
List all past psychiatric medications:_____________________________________________________________________________________________________________
List all bad drug reactions, side effects, food & drug allergies:_______________________________________________________________________________________________________________
If you have/had specific bad reactions or concerns about psychiatric medications, please explain_______________________________________
________________________________________________________________________________________________________________________
Problems, present or past with 1.Drug-Alcohol Yes[] No[] or, 2. Legal Y[] N[], like arrests, time in jail, juvenile detention, probation, please explain:
________________________________________________________________________________________________________________________
List All Psychiatric Medications Close And Distant Relatives Have Been On:
________________________________________________________________________________________________________________________
Have close or distant relatives have Drug and Alcohol Problems. Yes[ ] No[ ], or Impulse problems like Gambling Yes[ ] No [ ], with Eating Disorders Yes[ ] No [ ], with Legal Problems resulting in arrests, jail time, probation, fines, etc. Yes[ ] No[ ]
List 3 main problem your have, and what help you want, just information, a diagnosis, talk therapy, medications, other?
1._____________________________________________________________________________________________________________________
2._____________________________________________________________________________________________________________________
3._____________________________________________________________________________________________________________________
Read each item carefully, then 1. CHECK IF the Number APPLIES, THEN 2. CIRCLE the Specific Item to Clarify
1. [ ] Hyperactive, overly active, on the go, can’t sit still, and/or an inner sense of restlessness
2. [ ] Distractible, Sometimes? Mostly? Can’t concentrate, pay attention on boring stuff, for 15 minutes
3. [ ] Impulsive, doesn’t stop and think of consequences before talking or doing, or further thinking
4. [ ] Colicky as infant, presently unpleasant, irritable, nasty, mean, severe tantrums, bossy, the bully
5. [ ] Severe separation anxiety, frequent school absences, migraines, headaches, frequently ill, always sick
6. [ ] Short fuse, easily made angry, can’t calm self down within 20 min, severe temper, rage attacks
7. [ ] Mood swings, unpredictable, ups and downs of feelings, driven by moods, Dr Jekle & Mr.Hyde,
8. [ ] Can’t control anger, breaking things, self mutilating, dangerous to others, talks about killing others
9. [ ] Unaware of time, place, who you are, dazed, lost in time, confused, sleep like, or trance like states
10. [ ] Hurting self, cuts self, punches things, talk of suicide, being better off dead, dangerous to self
11. [ ] Sleep difficulties, sleeps too much/ too little, wakes up, dreams seem real, nightmares, wets bed,
12. [ ] Talks too much, too fast, not logical, difficult to follow, talks in circles, doesn’t always makes sense
13. [ ] Feeling sad, crying, saying negative things, not normal self, easily bored, things are less fun, isolates self
14. [ ] Excessive eating, especially in evening, waking up after asleep and eating, eats to calm down
15. [ ] Overly suspicious, holds grudges paranoid, thoughts seem like voices, odd, bizarre, strange, weird
16. [ ] Too worried, afraid to do things, go places, shy, stage fright, panic attacks, heart beats fast, sweats easily
17. [ ] Excessive eye blinking, facial movements, throat clearing, sniffing, snorting, coughing,
18. [ ] Does things over and over, rituals, touching, counting, hand washing, ordering, putting things in sequence
19. [ ] Gets angry/fearful to change in routines ,sensitivities to, sound, touch, light, taste, smells, foods
20. [ ] Poor eye contact, doesn’t seem to get social things like greetings, jokes, sorrows, need to love, to grieve
21. [ ] Delay or improper use of language, play-pretend get stuck on one idea over, especially sexual, violent
22. [ ] Over use or cant stop using drugs, alcohol, tobacco, exercise, food, TV, video games, computer time
23. [ ] Trouble in reading, spelling, math, other learning problems, speech, stuttering, co ordination difficulties
24. [ ] Witnessed domestic violence, victim of neglect, physical and/or sexual abuse, natural catastrophe
25. [ ] Cruel to animals, cruel to people, nasty, mean, seems to lack conscience, no or little remorse, guilt, shame