SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Psychiatry Assessment Tool

Preliminary Information:
Patient’s Initial:________________________ Age: ___ Sex Male Female Civil Status _______ Occupation______________
Informant: ___________________Relationship of Informant to patient: _______________ Religion ____________Ethnicity:__________
Place of Birth: ________________________Date of examination: ___________________ Area of assignment____________________
Psychiatric History
A. Chief complaint:__________________________________________________________________ Voluntary involuntary
B. Onset and Course of lllness: Age of onset_____ insidious Acute Precipitating event: _____________________________
Interventions done:____________________________________ Response to interventions:____________________________
C. Medical History:________________________________________________________________________________________
D. Family history:___ History of MI ___Parents’married? ___Parents living? ___________ Occupation of mother:___________
Occupation of father:__________ Quality of parental relationship: good fair poor
Family structure: nuclear extended w/:_____________ Single parent, W/:_______ same sex stepfamily
Family dynamics: harmonious understanding discordant separated Abusive
Quality of sibling relationship: ______________________________________________
E. Personal Developmental history:
1. Pregnancy: Planned unplanned Accepted unaccepted
2. Birth: institutionalized home delivery NSVD CS Term premature Biological child Adopted
3. Infancy: breastfed weaned when?_______ bottle-fed mixed major caretaker:______________
Termperament: difficult moderate easy
Attachment to parents: affectionate responsive detached rejecting unavailable others: ______________
4. Early childhood: started to walk: _________ Bladder training started:_____ bowel training started:_____ type of training:________
Activities: likes/dislikes:___________________________________________________________________________________
Emotionality: friendly shy possessive rebellious fearful lonely others: _____________________
Discipline pattern: authoritative authoritarian Permissive Uninvolved
Deprivations:_________________________________ other experiences: _______________________________________
5. Childhood: school entrance age: ____ school related problems: bullying learning problems: _____________________
Behavior problems:_____________________________ socialization problems: _________________________________
Emotional problems:______________________________ Childhood trauma: _________________________________
Childhood diseases: _______________________________________________________________________________
6. Adolescence: family problems: ___________________________ Communication with parents: open close limited
self image/concept concerns: ___________________________________ friendly aloof isolate others:_________
School related problems: bullying learning problems: ____________________________________________________
Behavior problems: rebellious trouble with school authority trouble with police delinquency truancy school
fights drug/alcohol use engagement in sex others: _____________________________
Emotional problems:__________________________________________________________________________________
7. Adulthood: school related problems: ___________________________ work related problems: ______________________
Financial concerns:_____________________________ relationship concerns:____________________________________
family related concerns: _________________________________________________________________________________
health related concerns: _________________________________________________________________________________
F. Social history : lives alone lives with: __________________________________________________
Mental Status Diagnosis:________________________________________________ CARE CONCERNS
Appearance: appropriate to age inappropriate to age; appears old appears young Self care deficit
sick weak well effeminate masculine Risk For Injury
Dressing: Appropriate to occasion? yes No Appropriate to the client’s age? yes no Thought alteration:
Are the clothes in reasonable repair?
____________________
Grooming and hygiene: shows reasonable care for hair? yes no tidy dirty foul odor
overdone make-up too neat Perceptual alteration:
Behavior: Cooperative indifferent withdrawn defensive calm bothered ____________________
Psychomotor status: hyperactivity psychomotor retardation bizarre mannerisms Twitching Impaired interaction
stiffness tremors relaxed hurried rigid Hyper-arousal ↑ vigilance/↑ startle process:_____________
Socialization & Interpersonal Relationships: guarded exaggerated aloof Hyperactivity
Speech: normal rate pressured slow halting rumbling intrusive mutism Restlessness
loud soft incoherent irrelevant neologisms echolalia clanging Fatigue
Affect/Mood: congruent to content inappropriate apathetic shallow blunted flat Sadness
euthymic reactive happy labile tearful sad irritable elated worried anxious

Copyright©2013SLUSoN 1
Thinking: Perception: hallucinations_________________ illusions:__________ delirious Fear/ Anxiety:_______
Form: logical concrete referential illogical scattered: goal-directed
Process disorganized circumstantial tangential looseness flight of ideas blocking Others:________
Content: appropriate persecutory trends paranoia hypochondriacal trends grandiosity
depressive trends poverty of thought others:__________________________
Orientation: time place person self Concentration: distractable inattentive
Memory: remote:________________ recent::_______________ immediate:_______________
amnesia hypermnesia confabulation
Insight: fair poor aware of limitations
aware of the consequences of actions
Judgment: compares evaluates facts/ideas/choices understands relationship
draws appropriate conclusions
Personal concerns Diagnosis:____________________________________________________ CARE CONCERNS
Low self esteem
Self-Concept: good low too high worthlessness Excess concern with appearance
Body image disturb
Development: stage, tasks and concerns:(Erickson)____________________________________________ Altered nutrition
Stress-Coping pattern? Sources of stress: ________________________________________________ Sleep pattern disturb
ways of coping: __________________ Substance use: type:____________ amount:________ Risk for injury
frequency:____________ Ineffective coping
Support system source:___________________________________ adequacy: _____________________ Impaired adjustment
Sexuality and sexual concerns? Sex Preference:_________ Sexual problems: ___________________ Powerlessness
Aids to sex performance:____________________________ others____________________________ Hopelessness
Sleep: hypersomnia insomnia not rested p sleep Amt of sleep:__hrs Aids to sleep: __________ Sadness/Depression
Appetite: loss increase purging amt of food per meal: _____ (%) Weight:_____ BMI:______ Inadequate support
Suicidal: ideation __ passive __active plan intent hopeless helpless Sexual disturb
Behavioral problems: : rebellious trouble with school authority trouble with police Anxiety
delinquency truancy school fights : rebellious trouble with school authority trouble problem/s:___________
with police Lack of empathy/remorse defiant vandalism others: _______________________ Physical problem/s:
Sadness/Depression: Low mood for >2 weeks Guilt/worthlessness Anergia/fatigue
Poor Concentration Psychomotor slowing indecisiveness ____________________
Medications/treatments: ____________________________________________________________ Others:____________
Feeling of anxiety: Trembling Palpitations Nausea/chills Choking/chest pain
Sweating Avoidance Repetitive behaviors:______________ Fears: ______________ ____________________
Phobia: _________ flashbacks of trauma Excess worry Restless/edgy Muscle ____________________
tension ____________________
Mediations/treatments for anxiety: __________________________
Health problems: _____________________________________________________________________
Meds taken: ________________________________ Lab results: _______________________________

Social Concerns Diagnosis:______________________________________________ CARE CONCERNS

Relationship issues: communication: ____________ respect:________ expectations impaired comunicati
demands, fidelity:___________ break‐up With whom?____________________________ Marital discord
Role conflict
SOCIAL PROBLEMS: (describe role, interaction pattern and concerns) Spiritual distress
Financial concerns(describe)_____________________________________________________________ Relationship
Food/water: _________________________________________________________________________ problems:___________
Others: __________
Housing/neighborhood concerns: ________________________________________________________
___________________
Work: _______________________________________________________________________________ ___________________
Neighborhood:_______________________________________________________________________ ___________________
Education:___________________________________________________________________________
Legal/police/military concerns: __________________________________________________________
Cultural/religious: _____________________________________________________________________
Environmental : ______________________________________________________________________
Family: (specify)_______________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
Relatives:___________________________________________________________________________
Friends:____________________________________________________________________________
others: specify_______________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

I do hereby certify that all information written on this assessment tool are true and correct.

Name of the Student _______________________________ Signature _____________________ Date ____________

Copyright©2013SLUSoN 2