Clinical Write-Up
History of Present Illness
Depression symptoms:
Can you describe your depression symptoms? What makes the depression better, what makes the depression worse? Does the depression, come and go?
Anxiety:
Does the anxiety come and go or is there all the time? Does anything make the anxiety worse or better? Do you go into panic? If so, how often and how long does it usually last?
Mood swings:
Do your moods go up and down? If so, can you tell me more about a typical mood swing?
Anger/irritability:
Do you get angry more than you should? How do you act when you get angry?
Clinical Write-Up
Attention and focus:
Do you have trouble concentrating or staying on track?
Current self-harm, suicidal/homicidal ideations:
Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself?
Hallucinations:
Do you ever hear or see anything that other people may not hear and/or see?
Paranoia:
Do you feel like people are talking about your or following you?
Clinical Write-Up
Sleep:
Do you have trouble falling or staying asleep? How long does it take you to fall asleep? Once you get to sleep, do you stay asleep all night or are you up and down throughout the night?
Past Psychiatric History
At what age did the mood symptoms start?
Do you have a previous psychiatric diagnosis? If so, what age and what was going on (if anything) around the time of the diagnosis?
Where there any environmental factors that could have contributed to the moods? For example, divorce, death in the family, etc. Do you feel like people are talking about your or following you?
Any previous treatment and if so, what was it and did it work? List any previous psychiatric medications have been tried and why the medication was stopped. APA.