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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Adult Assessment To be filled out by patients of Angela Heidorn that are 13 years of age or older Name: ____________________________ Cell#__________________ Date_______________ Patient is a ______ year-old year old (Race):________________________ (circle) male or female Who currently resides with (list people in the home). ________________________________________________________________________________ In (city and state) _______________________________ Patient is currently in the _________grade at (name of school) ____________________. Patient is currently employed by_____________________ as a(Title)______________________for the past (length of time)______________________________. PRESNTING PROBLEM: Patient was referred by ____________________________for problems with (please explain in detail) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________ Play Patient is currently experiencing the following symptoms :(Circle all that apply) Inability to pay attention / keep focus, being easily distracted, being restless and fidgety, being impulsive, being disorganized, low frustration tolerance, rapid mood swings, being easily stressed, poor self-esteem, a tendency toward addictive behaviors, family relations issues, oppositional behavior, education problems, peer conflict. excessive and /or unrealistic worry that is difficult to control, motor tension (such as restlessness, tiredness, shakiness and muscle tension), autonomic hyperactivity (such as shortness of breath, heart palpations, nausea and or diarrhea), hypervigilance (such as feeling on edge, trouble falling or staying asleep and irritability), social phobia, separation anxiety. depressed or low mood, suicidal thoughts and or actions, moody irritability, isolation from family or friends, lack of interest in previously enjoyable activities, low energy, low self-esteem and little or no eye contact, reduced appetite, increased sleep, poor concentration and indecision, feelings of hopelessness, worthlessness and inappropriate guilt, unresolved grief issues, mood related hallucinations or delusions. Other (Please explain) _____________________________________________________________________________________ _____________________________________________________________________________________ Please indicate how long patient has been experiencing the above symptoms.____________________________________________________________________________ Adult Assessment To be filled out by patients of Angela Heidorn that are 13 years of age or older PSYCHIATRIC HISTORY Prior outpatient psychiatric treatment in the past? Yes No When/Where?____________________________________________________________________ Treating Physician/s?_______________________________________________________________ Prior outpatient alcohol/substance abuse treatment? Yes No When/Where?_____________________________________________________________________ Prior outpatient treatment was helpful? Yes No Number of prior psychiatric hospitalizations:____________ Date of last psychiatric hospitalization:__________________ Number of prior alcohol or substance abuse hospitalizations: _______________ Date of last alcohol/substance abuse treatment: ______________________ Involuntary hospitalizations in past? Yes Prior history of non-suicidal injury? Yes No No Method of non-suicidal injury ( scratching, cutting, burning or other-___________________) Prior History of suicide attempt? Yes No Number of attempts______________ Date of Last attempt:_____________ Method of self harm:___________________ Attempt resulting in medical hospitalization: Yes Prior History of Aggression or Violence? Yes No No Aggression towards: _______________________________________ Legal charges stemming from aggression: Yes No Incarceration stemming from aggression: Yes No Prior Psychiatric medications tried:_________________________________________________________________________________ SUBSTANCE USE HISTORY Adult Assessment To be filled out by patients of Angela Heidorn that are 13 years of age or older Alcohol: (beer, wine, liquor) Yes No Date of last use_______________________ Frequency____________________ Cannabinoids: (marijuana, hashish) Yes No Date of last use_______________________ Frequency____________________ Opioids and Morphine Derivatives: (codeine, morphine, Heroin, opium) Yes No Date of last use_______________________ Frequency____________________ Stimulants: (cocaine, amphetamines, methamphetamines) Yes No Date of last use_______________________ Frequency____________________ Club Drugs: (MDMA, GHB) Yes No Date of last use_______________________ Frequency____________________ Dissociative Drugs: (Ketamine, PCP, Dextromethorphan Salvia) Yes No Date of last use_______________________ Frequency____________________ Depressants: (barbiturates, benzodiazepines) Yes No Date of last use_______________________ Frequency____________________ Hallucinogens: (LSD, Psilocybin, Mescaline) Yes No Date of last use_______________________ Frequency____________________ Anabolic steroids: (depo-testosterone, anadrol) Yes No Date of last use_______________________ Frequency____________________ Inhalants: (huffing, glue, solvents etc.) Yes No Date of last use_______________________ Frequency____________________ Intravenous drug use? Yes No Have you had any difficulties with any of the following issues related to substance use? Yes No TOLERENCE (increased amount of substance required to obtain initial effect of the drug) Yes No WITHDRAWAL (symptoms of physiologic or psychological distress upon stopping or reducing the amount of drug used) Yes No Consumption exceeds intended amount Yes Efforts to reduce/control consumption Yes No No Adult Assessment To be filled out by patients of Angela Heidorn that are 13 years of age or older Excessive time spent related to substance use and leading to disruption of daily functioning Yes No Additional Comments: _________________________________________________________________ PSYCHIATRIC SOCIAL HISTORY Were you adopted? Yes No Did your biological parents separate or divorce during your childhood? Yes Loss of parent by death prior to age 18 Yes No No Would you consider your childhood (circle one: happy, average, unhappy ) Was upbringing (circle one: lower, middle, upper) economic class During childhood, were you ever concerned about any form of Emotional abuse Yes No Explain:________________________________________________________________ Physical abuse Yes No Explain:________________________________________________________________ Sexual abuse Yes No Explain:________________________________________________________________ Education Highest Grade completed: _________________or current grade___________________ Did you earn a College or Graduate Degree Y N If what is your degree in?_____________________________ Special Educational Circumstances? Special Education Classes Y N Explain:___________________________________________________ GED earned Y N Vocational/Trade School Y N if so what is your trade?_______________________________________ Current Occupation: __________________________________________ Relationship Current Relationship Status:_______________________________ Have you ever been divorced? Yes No how many times________________________________ Adult Assessment To be filled out by patients of Angela Heidorn that are 13 years of age or older Current relationship is (circle one) poor fair good Are you currently sexually active? Yes Sexual Preferences? (circle one) No Opposite sex Same sex Bisexual Do you have any concerns or difficulties with sexual functioning? Yes No Are you pregnant? Yes No Not applicable Are you trying to get pregnant? Yes No Not applicable Number of children:________________________ Spirituality: none non-practicing active Legal Issues Prior difficulties with the legal system ever? Yes No Explain__________________________________________ Prior incarcerated Yes No Explain__________________________________________________________________ Current legal issues? Yes No Explain___________________________________________________________ Currently on Disability? Yes No Currently seeking Disability? Yes No MEDICAL HISTORY Patient and or family information Does Patient have any medical concerns?___________________________________________ Report surgeries_______________________________________________________________ Family History of Medical Concerns?_______________________________________________ Are patients Immunizations current? Yes No