TPR:

Height:

BP:

Weight:

Cardiovascular (CV)

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Heterocyclic antidepressants must be used with caution with cardiovascular disease. Tricyclic antidepressants (TCAs) may produce life-threatening

arrhythmias and ECG changes.

It is important to ask about any herbals, OTC medications (e.g., pseudoephedrine), or nontraditional treatments as client may not think to mention these when questioned about current medications. Important herbals include, but are not limited to: St. John’s wort, ephedra (ma huang), ginseng, kava kava, and yohimbe. These can interact with psychotropics or other medications or cause anxiety and/or drowsiness, as well as other adverse physiological reactions. Be sure to record and then report any additional or herbal medications to the psychiatrist, advanced practice nurse, psychiatric nurse, and professional team staff.

Central Nervous System (CNS)

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Remember that myasthenia gravis is a contraindication to the use of antipsychotics; tremors could be due to a disease such as Parkinson’s or could be a side effect of a psychotropic (lithium/antipsychotic). Sometimes the elderly may be diagnosed as having dementia when in fact they are depressed (pseudodementia). Use TCAs cautiously with seizure disorders; bupropion use contraindicated in seizure disorder.

Dermatological/Skin

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Lithium can precipitate psoriasis or psoriatic arthritis in patients with a history of psoriasis, or the psoriasis may be new onset. Acne is also a possible reaction to lithium (new onset or exacerbation), and lithium may result in, although rarely, hair loss (alopecia). Rashes in patients on carbamazepine or lamotrigine may be a sign of a life-threatening mucocutaneous reaction, such as Stevens-Johnson syndrome (SJS). Discontinue medication/immediate medical attention needed.

Endocrinology/Metabolic

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Clients on lithium should be observed and tested for hypothyroidism. Atypical and older antipsychotics are associated with treatment-emergent diabetes (need periodic testing: FBS, HgbA1c, lipids; BMI, etc).

Eye, Ears, Nose, Throat

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Eye pain and halo around a light source are possible symptoms of glaucoma. Closed-angle glaucoma is a true emergency and requires immediate medical attention to prevent blindness. Anticholinergics (low-potency antipsychotics [chlorpromazine] or tricyclics) can cause blurred vision. Check for history of glaucoma as antipsychotics are contraindicated.

Gastrointestinal

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Nausea is a common side effect of many medications; tricyclic antidepressants can cause constipation. Nausea seems to be more common with paroxetine. Over time clients may adjust to these side effects, therefore no decision should be made about effectiveness/side effects or changing medications without a reasonable trial.

Genitourinary/Reproductive

Does client have or ever had the following disorders/symptoms (include date):

CLINICAL PEARL: Antipsychotics have an effect on the endocrinological system by affecting the tuberoinfundibular system. Those on antipsychotics may experience gynecomastia and lactation (men also). Women may experience amenorrhea. Some drugs (TCAs), such as amitriptyline, must be used with caution with BPH. Postpartum depression requires evaluation and treatment (see Postpartum Major Depressive Episode in Disorders-Interventions Tab). Men should also be observed/evaluated for postpartum depression.

Respiratory

Does client have or ever had (include date):

Other Questions:

• Allergies (food/environmental/pet/contact) ____________________________________________
• Diet _________________________________________________________________
• Drug Allergies ________________________________________________________
• Accidents ____________________________________________________________
• High Prolonged Fever ________________________________________________
• Tobacco Use _________________________________________________________
• Childhood Illnesses __________________________________________________
• Fractures ____________________________________________________________
• Menses Began _______________________________________________________
• Birth Control _________________________________________________________
• Disabilities (hearing/speech/movement) ________________________________
• Pain (describe/location/length of time [over or under 3 months]/severity between 1 [least] and 10 [worst])/Treatment ______________________________________________________________________

Family History

• Mental Illness ________________________________________________________ ______________________________________________________________________
• Medical Disorders ____________________________________________________ ______________________________________________________________________
• Substance Abuse _____________________________________________________
• Please note who in the family has the problem/disorder.

Substance Use

Prescribed Drugs

Street Drugs

Alcohol