Dr. Kapoor's Mental Health Intake Template
Identifying Data:
Name
Age
Relationship/Marital status/length
Children/#/where/contact
Living situation
Employment/Training
Source of Income
Country of origin
Reason For Referral:
(Doctor’s words)
Chief Complaint:
Problem leading you to come here and duration
(Patient’s words)
History of Present Illness:
Time frame
Stressors
Symptoms
Coping strategies
Supports
Screen for Substance abuse
Screen for Mood
Depression (MSIGECAPS acronym from Toronto Notes)
Mania (GST PAID acronym from Toronto Notes) “ever find you have an extremely good mood for days, nothing can go wrong, feel on top of the world”
Screen for Anxiety
Panic Attacks (STUDENTS fear the 3Cs acronym from Toronto Notes)
GAD (BESKIM acronym from Toronto Notes)
OCD (“do you ever have excessive worries or thoughts that you go over and over for no reason, followed by acts/thoughts to feel better”?)
Phobias (fear of object or situation, “shy in social situations”?)
PTSD (“ have you ever had a traumatic experience that you still think about now? Ever relive any experiences?”)
Screen for Psychosis
Delusions (thought insertion and broadcasting)
Hallucinations –“ do you ever hear or see things that other people don’t”
Illusions
Screen SI/HI:
SADPERSONS (acronym from Toronto Notes), determine frequency, plan, intent, attempts
Past Psychiatric History:
Previous suicide attempts
Legal history
Hx of substance abuse (Nicotine, ETOH, Rx)
Admissions
Medical History:
R/O hx of HI, seizures, thyroid problem, frontal lobe injury, HIV, Syphilis
Hospitalizations
Sx
R/O B12/iron/folate deficiency
Check lytes and baseline cr/cbc/cholesterol/ECG for QTc
Medications:
Ask about caffeine and energy drinks
Allergies:
Personal History:
Developmental History: problems with pregnancy, developmental milestones, personality in school, friends in school, grades, high school, how old when you first started dating? Any history of abuse? Problems with the law?
School: Highest level of education
Relationships: current, past, longest
Occupational history: training, jobs, lengths
Family Psychiatric History:
Suicides
Substance abuse
Mental Status Exam
Appearance: age, groomed, walk
Behavior: movements, eye contact, cooperative
Speech: rate, volume, clear
Mood: what they say
Affect: quality, range, stable, appropriate, congruent
Thought Content: SI/HI, worries, delusions
Thought Process: coherence, logic, stream
Perception: hallucinations, illusions, depersonalization, derealization
Insight: into illness and treatment
Judgment:
Cognition:
Impression:
DSM-V Diagnosis
Patient Goals:
What are they hoping to achieve? Our expectations may be different from the patient’s
Diagnostic Pneumonics from TO Notes:
Mania: GST PAID
Grandiosity
Sleep - decreased
Talkative
Pleasurable activities - Painful consequences
Activity
Ideas - Flight of ideas
Distractibility
Depression: MSIGECAPS
Mood - depressed
Sleep - increased/decreased
Interest - decreased
Guilt
Energy - decreased
Concentration - decreased
Appetite - Increased/decreased
Psychomotor - agitation/retardation
Suicidal ideation
Panic Attacks: STUDENTS FEAR the 3 C's
Sweating
Trembling
Unsteadiness/dizziness
Depersonalization/Derealization
Excessive HR/palpitations
Nausea
Tingling
Shortness of breath
Fear of dying, loosing control, going crazy
3C: chest pain, chills, choking
Generalized Anxiety Disorder: BE SKIM
Blank mind
Easily fatigued
Sleep disturbance
Keyed up
Irritability
Muscle tension
Suicide Risk Factors: SAD PERSONS
Sex - male
Age > 60 years
Depression
Previous attempts
Ethanol abuse
Rationale thinking loss
Suicide in family
Organized plan
No spouse
Serious illness, intractable pain
~ Dugani, S. & Lam, D. (2009).Toronto Notes 2009. Toronto: Toronto Notes for Medical Students Inc.