Chief Complaint Why are you seeing this person? What is their most presenting problem?
Appearance Apparent age, height, weight, and manner of dress and grooming. Physical features of alcoholism, drug abuse or malnutrition. Dress, movements, body posture.
Attitude Attitude, rapport and cooperation.
Behavior General observations of the patient's level of activity and arousal, eye contact and gait.
Mood and Affect Alexithymia, anhedonia, appropriateness, blunted, exaggerated, lability, constriction.
Speech Loudness, rhythm, prosody, pressure.
Thought Process Quantity, tempo (rate of flow) and form (or logical coherence) of thought. Circumstantiality, coherence.
Thought Content Suicidal thoughts, depressed cognition, delusions obsessions, phobias, preoccupations, revenge fantasies.
Insight & Judgment Level of understanding of their problems. Capacity to make sound decisions.
Occupational Functioning Highest level of education, what jobs held, how steady, committed and how long. Pleasure & competence. Income. Financial resources. Particular skills and talents.
Family Functioning Married, single, how harmonious, how long, how many kids – capacity to take care of kids, understanding of needs of family members, capacity to negotiate own needs within family.
Intimacy History of and capacity for sustained reciprocal relationships.
Trauma History Ages, nature and effects on current life.
Trauma Symptoms Flashbacks, nightmares, avoidance, re-enactments, affect regulation, capacity to pay attention and concentrate, identity as victim.
Existence of Parts/Dissociation
What does the person do for Self-Care Sports, religious/spiritual, yoga, martial arts, dancing, music, gardening etc.
What does it feel like for you to sit with this person
Prior treatments What worked and what didn’t.
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