Kingdom of Saudi Arabia
Ministry of Higher Education
Majmaah University
College of Applied Medical Sciences
Quality & Skills Development Center
ةيدوعسلا ةيبرعلا ةكلمملا
يلاعلا ميلعتلا ةرازو
ةعمجملا ةعماج
ةيقيبطتلا ةيبطلا مولعلا ةيلك
تاراهمل ا ريوطت و ةدوجلا زكرم
Date: __________________________________________________
Student Name: ___________________________________________
Student No.: ____________________________________________
Student Signature: ________________________________________
1

IDENTIFYING INFORMATION
Patient's name:___________________________________________
Room No:______________
Primary Care Provider:___________________________________________________
DOB:____________________
Age:_____________________
Sex:_____________________
Race:____________________
Ethnicity:_________________
Nationality:________________
Religion: ______________________________________________________________
RELEVANT SOCIAL HISTORY
Marital status (for how long)
Married:________________________
Divorced:_______________________
Separated:______________________
Widowed:_______________________
Occupation/School (current/former):_________________________________________
Highest education level:__________________________________________________
Religious affiliation:______________________________________________________
City of residence:________________________________________________________
Name/phone No. of significant others:________________________________________
Primary language spoken:_________________________________________________
CURRENT PSYCHIATRIC HOSPITALIZATION
Date of hospitalization:___________________________________________________
Admitting Dr:___________________________________________________________
Admitted by:
By self (voluntary admission):______________________________________________
By police:______________________________________________________________
By family member:_______________________________________________________
2

By court order:__________________________________________________________
Accompanied by: _______________________________________________________
Admitted from:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Reason for current admission:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Chief complaints on current admission (in patient's own words):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PREVIOUS PSYCHIATRIC HOSPITALIZATIONS
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3

DSM-IV-TR Diagnosis
Previous Diagnoses (list all)
______________________________________________________________________
______________________________________________________________________
Current Diagnosis:
______________________________________________________________________
______________________________________________________________________
Nursing diagnosis:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
FAMILY HISTORY/INFORMATION
Family members/significant others living at home
______________________________________________________________________
______________________________________________________________________
Family members/significant others not living at home
______________________________________________________________________
______________________________________________________________________
Children
______________________________________________________________________
______________________________________________________________________
Family members suffering from mental illness
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
4

Spiritual beliefs
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Cultural practices: (including beliefs regarding mental illness)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PAST PSYCHIATRIC TREATMENTS
List the most recent admissions
Facility/location Dates
(from/to)
Diagnosis Treatments Comments
CURRENT PSYCHOTROPIC MEDICATIONS
List the most recent medications
Name Dose Treatment length
Response Comments
5

MEDICAL HISTORY
Temperature:___________________________________________________________
BP:___________________________________________________________________
Respiration:____________________________________________________________
Height:________________________________________________________________
Weight:________________________________________________________________
REVIEW OF SYSTEMS
Describe by reviewing the chart/ asking the client)
Cardiovascular:_________________________________________________________
Endocrine:_____________________________________________________________
Gastrointestinal: ________________________________________________________
Genitourinary:__________________________________________________________
Musculoskeletal:________________________________________________________
Central nervous System:__________________________________________________
Respiratory: ___________________________________________________________
Dermatology:___________________________________________________________
Eyes/Ears/Nose/Thrat:____________________________________________________
OTHERS
Allegies:_______________________________________________________________
Diet:__________________________________________________________________
Drug allergies:__________________________________________________________
Accidents:_____________________________________________________________
Tobacco use:___________________________________________________________
Childhood illness:________________________________________________________
Fractures:______________________________________________________________
Birth control:____________________________________________________________
Disabilities:_____________________________________________________________
Pain:__________________________________________________________________
6

DIAGNOSTIC TESTS (EKG, CT, MRI, EE)
Name of Test Date of Test Normal Range Client Values Comments
APPEARANCE
Grooming/Dress:________________________________________________________
Hygiene:_______________________________________________________________
Eye contact: ___________________________________________________________
Posture:_______________________________________________________________
Identifying features (marks/scares/tattoos):____________________________________
Appearance versus stated age:_____________________________________________
Overall appearance:_____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
7

BEHAVIOR/ACTIVITY
Hyperactive:____________________________________________________________
Psychomotor retardation:__________________________________________________
Psychomotor agitation:___________________________________________________
Anergia:_______________________________________________________________
Calm:_________________________________________________________________
Tremors:______________________________________________________________
Tics:__________________________________________________________________
Unusual movements/gestures:_____________________________________________
Catatonia:_____________________________________________________________
Akathisia:______________________________________________________________
Akinesia:______________________________________________________________
Apraxia (lack of purposeful movements):_____________________________________
Dyskinesia:____________________________________________________________
Dystonia:______________________________________________________________
Echopraxia:____________________________________________________________
Rigidity:_______________________________________________________________
Facial movements:_______________________________________________________
Other:_________________________________________________________________
8

SPEECH
Slow/rapid:_____________________________________________________________
Pressured:_____________________________________________________________
Tone:_________________________________________________________________
Volume:_______________________________________________________________
Fluency:_______________________________________________________________
Aphasia:_______________________________________________________________
Muteness:_____________________________________________________________
Poverty of speech:_______________________________________________________
ATTITUDE
Cooperative/uncooperative:________________________________________________
Warm/friendly/distant:____________________________________________________
Suspicious:____________________________________________________________
Argumentative__________________________________________________________
Guarded:______________________________________________________________
Aggressive:____________________________________________________________
Hostile:________________________________________________________________
Aloof (cold):____________________________________________________________
Apathetic (indifferent):____________________________________________________
9

Ambivalence:___________________________________________________________
Negativism:____________________________________________________________
Other:_________________________________________________________________
MOOD AND AFFECT
Elated/sad/depressed:____________________________________________________
Irritable:_______________________________________________________________
Anxious:_______________________________________________________________
Fearful:________________________________________________________________
Guilty:_________________________________________________________________
Worried:_______________________________________________________________
Angry:________________________________________________________________
Hopeless/Helpless:______________________________________________________
Labile (unstable):________________________________________________________
Mixed (anxious and depressed):____________________________________________
Flat:__________________________________________________________________
Blunted (dull) or diminished:_______________________________________________
Appropriate/inappropriate:_________________________________________________
Incongruent (sad and smiling/laughing):______________________________________
Other:_________________________________________________________________
10

THOUGHT PROCESS
Concrete thinking:_______________________________________________________
Circumstantiality:________________________________________________________
Tangentiality (off the topic):________________________________________________
Loose association:_______________________________________________________
Echolalia:______________________________________________________________
Flight of ideas__________________________________________________________
Perseveration (repetition of same thought/phrase/motor response):_________________
Clang association:_______________________________________________________
Blocking:______________________________________________________________
Ward salad:____________________________________________________________
Derailment:____________________________________________________________
Neologism:____________________________________________________________
Other:_________________________________________________________________
THOUGHT CONTENT
Delusions: _____________________________________________________________
Grandiose:_______________________________________________________
Persecution:______________________________________________________
Reference:_______________________________________________________
Somatic:_________________________________________________________
11

Nihilism:_________________________________________________________
Suicide/homicide thoughts:________________________________________________
If homicide, toward whom?:________________________________________________
Obsessions:____________________________________________________________
Paranoia:______________________________________________________________
Phobias:_______________________________________________________________
Magical thinking:________________________________________________________
Poverty of speech:_______________________________________________________
Other:_________________________________________________________________
PERCEPTUAL DISTURBANCIES
Visual hallucinations:_____________________________________________________
Auditory hallucinations:___________________________________________________
Commenting:______________________________________________________
Commanding:_____________________________________________________
Discussing:_______________________________________________________
Loud:____________________________________________________________
Soft:_____________________________________________________________
Other:___________________________________________________________
Olfactory Hallucination:___________________________________________________
12

Tactile
(formication):___________________________________________________________
Gustatory:_____________________________________________________________
Illusions:_______________________________________________________________
______________________________________________________________________
Depersonalization:_______________________________________________________
MEMORY/COGNITIVE
Orientation (oriented/disoriented):___________________________________________
Time:___________________________________________________________
Place:___________________________________________________________
Person:__________________________________________________________
Memory:______________________________________________________________
Recent:__________________________________________________________
Remote:_________________________________________________________
Confabulation (filling in gaps):________________________________________
Amnesia:_________________________________________________________
Level of alertness:__________________________________________________
Delirious:_________________________________________________________
13

INSIGHT AND JUDGMENT
Insight (present/absent):__________________________________________________
Full:_____________________________________________________________
Partial:___________________________________________________________
Judgment (good/bad):_______________________________________________
Other:___________________________________________________________
Impulse control:____________________________________________________
Other:___________________________________________________________
CLIENT GOALS FOR CLINICAL DAY
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
STUDENT GOALS FOR CLINICAL DAY
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
14