Download Adult Assessment

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