Observed Interview Questions

To be filled out by the student

PATIENT NOTE

HISTORY: Include significant positives and negatives from history of present illness, past medical history, review of system(s), social history, and family history.

MENTAL STATUS EXAMINATION: Indicate only pertinent positive and negative findings related to the patient's chief complaint.

DIFFERENTIAL DIAGNOSES: In order of likelihood on Axis I

Axis I ________________________________________________________________

Axis II ________________________________________________________________

Axis III ________________________________________________________________

Axis IV ________________________________________________________________

Axis V ________________________________________________________________

DIAGNOSTIC WORKUP: List immediate plans (up to 5) for further diagnostic workup:

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

4. ______________________________________________________________

5. ______________________________________________________________

Patient's rating of the student:

1. Did the interviewer introduce himself/herself? Yes No

2. Did the interviewer appear to be too intrusive in questioning? Yes No

3. Were you asked questions about alcohol/drug intake? Yes No

4. Were you asked about your pregnancy? Yes No

5. Were you asked questions about suicidal intent? Yes No

6. Did the interviewer make you feel comfortable? Yes No

7. Would you like to comment on the interviewer's style/manners or other aspects?