Name:

Age:

CC:
PI:

Life event:

A. Past history
1. Drug or food allergy: no known allergy
2. Systemic disease:
3. Surgical history:
4. Head injury / epilepsy:
5. Tobacco, alcohol, and betel nuts:
6. Illicit substance:
7. Seizure history: none
8. Violence history: none
9. Suicide history: none
10. Lawsuit event: none
11. Other: deferred

B. Personal history
1. Birth history and development history: as milestones
2. School history and achievements:
3. Occupational history:
4. Interpersonal relationship:
5. Marriage history:
6. Religion:
7. Premorbid personality:
8. Other:
C. Family history
1. Key person and caregiver:
2. Family history of psychiatric illness:
3. Specific problems of family:
4. Family pedigree:

----------------------A. Physical Examination

1. Vital signs:
BW:

kg

BH:

cm

Temperature/Pulse rate/Respiratory rate/:

Blood pressure (systolic/diatolic):
HEENT: normal
Chest: bilaterally clear breath sounds
Heart: regular heartbeats, no murmurs
Abdomen: soft, no tenderness, normoactive bowel
Extremities: freely full ranges of motion, no edema
B. Neurological Examination
Muscle power: 5+, bilateral symmetric
Muscle tone: normal, bilateral symmetric
C. Mental Status Examination
1. Consciousness: alert
2. General appearance: kempt

3. Attitude: cooperative
4. Attention and concentration: intact
5. Mood and affect: depressed mood, restricted affect
6. Speech: coherent and relevant
7. Behavior: no queer behavior
8. Thought: no delusion
9. Perception: no auditory or visual hallucination
10. JOMAC:
Judgement: intact
Orientation: intact to person, time, and place
Memory: immediate: intact
recent: intact
remote: intact
Abstract thinking: intact
Calculation: intact
11. Insight: partial insight
12. Somatic Complaint: none
[Axis I]
[Axis II]
Deferred
[Axis III]
Deferred
[Axis IV]
Deferred
[Axis V]
GAF:

Problem 1:
S:
O:
A:
P:
[Biological]
[Psychological]
[Social]