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Date:________________________________ Patient Name:________________________ Referred by:_________________________ Mailing Address:_____________________ Telephone:___________________________ Your Email Address:__________________ Date of Birth:_______________________ Gender: Male Female Primary Care Physician Name, Address and Phone:__________________ Emergency Contact Name:______________ Relationship:________________________ Phone:_______________________________ Your Height:_________________________ Your Weight:_________________________ What seems to be the problem? What is the reason for consultation? These are basic questions. There are many more. What best describes problem of the patient? Sleep problems. Anger. Relationship problem. Not taking care of self. Not taking care of others. Misinterpreting the facts. Recent social withdrawal or loss of interest in others. Illogical thinking typical of childhood but in an adult. Repeatedly checking or doing activities that seem abnormal. Restlessness. Administrative abuse/harms from others. Thoughts or threats to hurt oneself or others. Social withdrawal after death of a person known to the patient. Communication problem (speech, writing, reading, expression). Not enough food, clothing, housing needs, transportation, health care, or education. Other issues. You need to give details of the issues or problems. Life-threatening conditions. Suicidal thoughts. Homicidal thoughts. Assault, violent actions or behavior. Delirium or extreme agitation. Feeling that harms have been inflicted or are being inflicted, and that harms are going to be inflicted that need to be prevented. Is the claim any one of these? Psychological torture Physical torture Corruption in politics of regulations Racism Deprivations of rights under the color of law Political abuse Discrimination Disruption Exclusion Did anyone beat or torture you at any point since birth? Did anyone abuse or scold you that caused and is causing distress to you since birth? Is there any incident or issue in past, present, or future that is causing distress to you? Did you experience any one of these that has troubled you since the day you were born? Assault. Accidents. Child abuse or captivity. Childbirth. Death of a loved one. Fire. Rape. Natural disaster (hurricanes, earthquakes, tsunamis). Road traffic crash. Building collapse. Fire. Shooting. Neglect of a child leading to a serious harms. Domestic violence. War. Genocide. Torture. If yes, what are the details? If any other traumatic, stressful, harmful, or horrifying event, give more details. |
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Psychiatric medical emergencies
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