Comprehensive Psychiatric Intake

Reason for Visit: - [describe reason for visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) History of Present Illness: - [describe history of present illness, including onset, duration, and progression of psychiatric symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Past Psychiatric History: - [describe past psychiatric history, including hospitalisations (e.g. admissions to district, regional, or psychiatric hospitals), treatments, diagnoses, and outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Past Medical History: - [describe past medical history, focusing on any conditions that may impact psychiatric health, e.g. HIV, TB, epilepsy, diabetes, hypertension] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medications: - [mention current medications, including psychiatric medications and dosages, including chronic medication dispensed via state clinic or private pharmacy] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Allergies: - [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Medication Trials: - [describe previous psychiatric medication trials, including efficacy and side effects] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Access to Weapons: - [describe access to weapons or firearms, including whether kept at home or by family members] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Social History: - [describe social history, including living situation (e.g. informal settlement, RDP house, with family, boarding), relationships, and available support systems] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Education: - [describe education history and current educational level, including school attendance, learning barriers, and highest grade passed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Relationships: - [describe interpersonal relationships, including family dynamics, intimate partnerships, and caregiving responsibilities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Work: - [describe work history, current employment status (e.g. unemployed, informal work, SASSA grant recipient), and work-related stressors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Supports: - [describe supports, including family members, neighbours, community mental health services, NGOs, or clinic-based services] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Protective Factors: - [describe protective factors, such as positive coping strategies, religious involvement, family support, or future goals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Negative Factors: - [describe negative factors or stressors, such as substance use, intimate partner violence, lack of family support, unemployment, or housing instability] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Suicide Risk Assessment: - [describe suicide risk assessment, including ideation, intent, plan, access to means, previous attempts, and protective factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Forensic History: - [describe legal history, including arrests, charges, protection orders, bail, parole, or history of forensic psychiatric assessments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Family History: - [describe family psychiatric and medical history, including any history of schizophrenia, bipolar disorder, suicide, substance abuse, or chronic illness in close relatives] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Mental Status Exam: - [describe mental status exam findings, including appearance, behaviour, speech, mood, affect, thought process, thought content, hallucinations, cognition, insight, and judgement] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Objective Findings: - [describe objective findings, such as physical examination findings, blood pressure, weight, HIV/TB/Viral Load/CD4 status if relevant] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Diagnosis: - [mention diagnosis based on DSM-5 or ICD-10 criteria used in public or private sector South African mental health settings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Diagnostic Formulation: - [describe diagnostic formulation, including biopsychosocial contributors to mental illness such as trauma, substance use, family conflict, or socioeconomic stress] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Assessment and Plan: - [describe assessment and plan, including treatment goals, medication changes, referral to state mental health services or psychology, admission if applicable, and follow-up recommendations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or continuing care — use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned — just leave the relevant placeholder or section blank.) (Use as many bullet points as needed to capture all the relevant information from the transcript.)