PRELIMS

• Identify the patient:

  • Patient’s name
  • Languages spoken
  • Ethnicity
  • Race
  • Marital status
  • Birthdate/ Age
  • Gender
• History of Present Illness: Problem's location, Duration, Severity, Timing, Context, Modifying factors, & Associated signs or symptoms
• History of Alcohol and Drug use: Method of use (oral, inhalation, injection, intranasal), Amount, Frequency, and Time.
• Common abuse substances: alcohol, heroin, opiates, marijuana, cocaine, crack, methamphetamines, inhalants, stimulants, hallucinogens, caffeine, and nicotine.
• Violence Risk Assessment:

  • Suicidal Ideation
  • Homicidal Risk
  • Abuse

  Social History:

  • Patient should describe their social relationships, including several siblings, who raised the patient, spouse, or significant other, several children, current living situation, military history including the type of discharge, and any additional support or social networks reported.