Hope & Faith Wellness Clinic - Medical/Psychiatry/Social history
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Full Name: *
DOB: *
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Age: *
CURRENT PROBLEMS
Please list problems, Duration (How long it's been existent) and any other info in same order.
1. Problems, Duration, Info: *
2. Problems, Duration, Info:
Symptoms Checklist: *
NONE - This symptom is not present at this time • MILD - Impacts quality of life, but no significant impairment of day-to-day functioning • MODERATE - Significant impact on quality of life and/or day-to-day functioning • SEVERE - Profound impact on quality of life and/or day-to-day functioning
None
Mild
Moderate
Severe
Depressed Mood
Appetite Disturbance
Sleep Disturbance
Social Isolation
Fatigue/Low energy
Psychomotor retardation
Lack of Interest
Poor Grooming
Guilt
Hopelessness
Grief
Sexual dysfunction
Worthlessness
Euphoric mood
Mood swings
Irritability
Hyperactivity
Racing thoughts
Poor concentration
Aggressive behaviors
Oppositional behavior
Panic attacks
Anxiety
Phobias
Obsessions/compulsions
Nightmares
Hallucinations
Paranoid ideation
Delusions
Binging/Purging
Anorexia
Self-mutilation
Significant weight gain/loss
Laxative/diuretic abuse
Substance abuse
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