Preliminary Evaluation Template

History of Presenting Complaints:  
John Doe, a 35-year-old male, came in with ongoing feelings of sadness, disinterest in daily activities, and fatigue for the last six months. He reports trouble sleeping and concentrating, which has impacted his job performance. John also noted experiencing occasional panic attacks with symptoms of shortness of breath and palpitations.
Psychiatric Review of Systems:  
- Depression: Ongoing sadness, lack of pleasure, fatigue, insomnia, trouble concentrating  
- Mania: Not reported by client  
- Anxiety: Panic attacks, restlessness  
- Psychosis: Not reported by client  
- Trauma: Not reported by client  
- Eating Disorder: Not reported by client  
- ADHD: Not reported by client  
- Autism Spectrum: Not reported by client  
- ODD / Conduct / Antisocial: Not reported by client  
- Personality Disorder: Not reported by client  
Past Psychiatric History:  
- Diagnosed with Major Depressive Disorder two years ago, treated with cognitive behavioral therapy  
- No hospitalizations  
- Currently on Sertraline 50mg daily  
- Previously tried Fluoxetine  
Past Medical History:  
- Hypertension, managed with Lisinopril  
- Appendectomy at age 20  
Family History:  
- Mother has Bipolar Disorder  
Substance use History:  
- Occasional alcohol use, last consumed two weeks ago  
- No history of smoking or recreational drug use  
Social History:  
- Born and raised in Chicago, currently residing in New York with his wife  
- Employed as a software engineer, holds a bachelor's degree in computer science  
- Strong social support from family and friends  
- No current legal issues  
Risk Assessment:  
- No current suicidality or homicidality  
Diagnosis: Major Depressive Disorder, Generalized Anxiety Disorder  
Treatment Plan:  
- Continue Sertraline 50mg daily  
- Schedule family meeting to discuss support strategies  
- Refer to psychologist for ongoing therapy  
- Follow-up appointment in four weeks