BMW Biopsychosocial Client History Form

  • BMW Biopsychosocial Client History Form

  • Date
     / /
  • Date of birth
     / /

  • Biopsychosocial History

    Presenting Problems

  • Current Symptom Checklist (Rate intensity of symptoms currently present)

    Mild = Impacts quality of life, but no significant impairment of day-to-day functioning

    Moderate = Significant impact on quality of life and/or day o-day functioning 

    Severe = Profound impact on quality of life and/or day-to-day functioning

     

  • Rows

  • Emotional/Psychiatric History

  • Prior outpatient psychotherapy?

  • If yes, on occasions. Longest treatment by for        sessions from       /     to         
    /      

  • Rows
  • Has any family member had outpatient psychotherapy?
  • Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?

  • If yes, on occasions. Longest treatment at from   Pick a Date   to   Pick a Date   

  • Rows
  • Prior or current psychotropic medication usage?
  • Rows
  • Has any family member used psychotropic medications?
  • Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder?

  • Family History

    Family of Origin
  • Rows
  • Rows
  • Parents' current marital status

  • separated for years

  • divorced for years

  • mother remarried times

  • father remarried times

  • mother deceased for years
    age of patient at mother's death      

  • father deceased for years
    age of patient at father's death      

  • Describe childhood family experience

  • Immediate Family

  • Marital status

  • enganged      months

  • married for      years

  • divorced for      years

  • seperated for      years

  • divorce in process      months

  • live-in for      years

  •     prior marriages (self)

  •     prior marriages (partner)

  • Intimate relationship
  • Relationship satisfaction
  • Rows
  • Rows

  • Medical History

    (check all that apply for patient)
  • Describe current physical health

  • List name of primary care physician

  • Format: (000) 000-0000.

  • List name of psychiatrist (if any):

  • Format: (000) 000-0000.
  • Is there a history of any of the following in the family
  • Rows
  • Rows

  • Substance Use History

    (check all that apply for patient)
  • Family alcohol/drug abuse history
  • Substance use status
  • Rows
  • Patient Treatment history
  • Rows
  • Consequences of substance abuse

  • Development History

    Check all that apply for child/adolescent patient
  • Problems during mother's pregnancy
  • Birth

  • birth weight      lbs      oz.

  • Infancy Problems
  • Rows
  • Delayed developmental milestone (check only those milestones that did not occur at expected age):
  • Emotional / behavior problems (check all that apply)
  • Social interaction
  • Intellectual / academic functioning

  • Socio-Economic History

  • This is a fill in the field. Please add appropriate fields and text.

  • Living situation
  • Social support system
  • Military
  • Employment
  • Financial situation
  • Legal history

  • jail/prison time(s)

  • Sexual history

  • history of promiscuity age to

  • history of unsafe sex age to

  • Activities
  • Sources of Data Provided Above
  • Presenting Problems/Symptoms
  • Family History
  • Developmental History
  • Emotional/Psychiatric History
  • Medical/Substance Use History
  • Socioeconomic History
  •  
  • Should be Empty: