• DEMOGRAPHICS

  • PRESENTING COMPLAINT

  • PAST PSYCHIATRIC HISTORY

  • PAST MEDICAL HISTory

  • DRUG AND ALCOHOL

  • FORENSIC HISTORY

  • PERSONAL HISTORY

  • MENTAL STATE

    • Age, sex
    • Dx
    • Rx by - team, doctor, DN
    • living circ
    • industry/finances
    • supports
    • MHA, EPOA, etc
  • PERSONALITY DYSFUNCTION

  • Sleep Apnoea Sx
    thyroid Sx
    bloods/scans

  • DEVELOPMENTAL HISTORY

  • SPEECH

  • emotional dysregulation
    Anger outbursts
    cutting/self harm
    Perceived insults/insecurity.

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