Psychiatric Physical Exam

Identifying Information:
Age, sex/gender, marital status,
religion, employment, living condition
Chief Complaint
HPI: OPQRST
Onset, precipitants, quality,
radiation, severity, timing
Past Psychiatric History
First contact, hospitalization, Rx,
Psychotherapy, SI, suicide
attempts, self harm, other
Substance Abuse History
Name drug, amount and duration,
precipitants, Hx of withdrawal,
sobriety, past treatments
Past Medical History

Medications
Allergies
Family History
Social History
Mental Status Exam
• General Appearance,
Behavior and Attitude
• Mood & Affect
• Psychomotor Activity
• Thought process and
attitude
• Thought content
• Sensorium and
Cognition
Psychiatric Review of Systems
Sleep
Depressive Sx (SIGECAPS)
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal

Anxiety sx

OCD sx

PTSD sx
Flashbacks, trouble in crowds,
avoidance or isolation,
negative affect, depressive sx
Distractibilty and easy frustration
Mania (DIGFAST)
Irresponsibility
Grandiosity
Fight of ideas
Activity increased with weight loss
Sleep is decreased
Talkativeness
Psychosis
• Delusions
• Hallucinations