Patient Interview Template

IDENTIFYING INFORMATION
Age:
Sex:
Race:
Marital status:
Employment status:
CHIEF COMPLAINT/MAJOR LIFETIME PROBLEM (use patients own words)

HPI (include pertinent negatives, current psychotropic medications)

PAST PSYCHIATRIC HISTORY

Initial symptoms/symptoms not currently of concern:

Prior treatment and response to treatment:

Other psychiatric disorders that have resolved:

FOCUSED MEDICAL HISTORY

Current illnesses:
Medications:
Allergies:
Prior serious illness or surgeries:
Reproductive history:
Pertinent negatives:
SUBSTANCE USE HISTORY (pattern of use, longest periods of abstinence, use of self-help or professional
resources)
Drugs:
Alcohol:
Cigarettes:
FAMILY PSYCHIATRY HISTORY (first- and second-degree relatives)
Mental illnesses:
Suicides:
Substance abuse:

SOCIAL/DEVELOPMENTAL HISTORY
Family of origin:
Members:
Ethnic background:
Social background:

Relationship between parents:

Parents relationship to children:
Major life events (moves, divorces, deaths):
School history:
Early friendships:
Adolescent behavior:
Intimate relationships:
College/military history:
Adult work history:
Adult relationships:
Marriages:
Relationships with children:
Current social situation:
Current job stability:
Financial difficulties/resources:
Supportive/problematic relationships:

MENTAL STATUS EXAMINATION (include pertinent negatives)

Appearance
Dress:
Grooming:
Weight:
Motor behavior:

Eye contact:
Level of consciousness:
Attitude toward interview:
Speech:
Thought process:
Affect:
Mood:
Perceptions:
Hallucinations:
Illusions:
Thought Content:
Delusions:
Ideas of reference:
Preoccupations (main themes/concerns):
Suicidal/assaultive thought, plans, intentions:
Formal cognitive tests:
Orientation:
Attention:
Concentration:
Registration and short-term memory:
Calculations:
Abstraction:
Fund of knowledge:
Vocabulary:
Insight (into source of symptoms or into personal motivations, qualities):
Tested judgment, personal judgment:
MULTIAXIAL DIAGNOSIS
Axis I: Main provisional diagnoses, diagnoses to consider also

Axis II: Possible maladaptive personality traits

Axis III: Current medical problems, medical problems contributing to current condition

Axis IV: Main stressors

Axis V: Global assessment of function (use published scale in DSM-IV)

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"It sounds as if Holly has had a fever for a few days. Can you tell me a little more about her illness?"
"Has she had any runny nose, congestion, cough or difficulty breathing?"
"Has Holly had any vomiting or diarrhea?"
"Has Holly been urinating more frequently, has she had any blood in her urine, or has her urine had
any unusual odor?"
"Has she had any skin rashes or sores in her mouth?"
"You said Holly was fussy. Does she respond to you when you try to comfort her? Does she
recognize you and other familiar faces?"
"Has Holly had any recent trauma?"
"Has Holly had any redness or swelling of her joints or extremities?"

The term fever

without source (B) is used when a complete history has been

obtained and a detailed physical examination performed, and there is no identified
source of the child's fever.
Fever Without Source

Far and away the most common cause of fever without source in this age group is a viral syndrome. A small
minority of children, however, may have a

serious bacterial illness (SBI). Etiologies of SBI

include the following:

Urinary tract infection (UTI)--the most common

Meningitis

Sepsis

Pneumonia

Bacterial gastroenteritis

Osteomyelitis

Septic arthritis

Occult bacteremia

Fever of unknown origin (A) is defined as a temperature greater than 38.3 C (101 F) for at least two weeks'
duration with failure to reach a diagnosis after one week of evaluation.
Sepsis (C) is a severe systemic illness caused by overwhelming infection of the bloodstream by toxinproducing bacteria. A diagnosis of sepsis typically requires positive blood cultures.