Download Medical Evaluation Questions - BRP Health Management Systems

Medical Evaluation Questions
Your patient has been referred for services at the John T. Raukar Institute. We understand that the
patient’s physical health will directly impact their ability to fully benefit from the treatment provided
by the Institute. We ask that all patients receive a full history and physical to determine the following
diagnostic questions:
Diagnostic Questions: To what extent has drug and alcohol use negatively impacted the child’s health?
General Health
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Does the patient have a psychiatric condition that currently requires psychiatric hospitalization?
Does the patient have a medical condition that requires ongoing medical care?
Is the patient medically stable?
Does the patient have a communicable disease that may be contagious to others?
Does the patient require detoxification services?
Does the patient present a significant risk of harm to themselves, other patients or staff?
Does the patient require special attention for medical or psychiatric care?
Sexuality
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Are you or have you been sexually active?
Have you ever been pregnant or had an abortion?
Do you have any sexually transmitted diseases--knowledge and prevention? Contraception?
How often do you use contraception -- knowledge and prevention? Contraception?
Have you ever been sexually or physically abused?
If the physician feels testing for sexually transmitted disease testing is required please indicate the
results.
Suicide/Depression
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Sleep disorders (usually induction problems, also early/frequent waking or greatly increased sleep
and complaints of increasing fatigue)
Appetite/eating behavior changes
Feelings of 'boredom'
Emotional outbursts and highly impulsive behavior
History of withdrawal/isolation
Hopeless/helpless feelings
History of past suicide attempts, depression, psychological counseling
History of suicide attempts in family or peers
History of recurrent serious 'accidents'
Please provide the patient with a tuberculosis screening test
Please ensure the Patient is up to date on all immunizations and complete the attached
Immunization record.
Medical Evaluation Questions
A. HEALTH/MEDICAL:
1. MEDICAL HISTORY: (Indicate how the mental illness impacts this area)
a. History of any major non-psychiatric illnesses:
b. Surgeries:
c. Hospitalizations: (what, when, why, where)
d. Dates of last examinations: (include physical, dental, and eye exams)
e. Pertinent family history of medical illness: (who, what, when)
f.
Current health problems/needs: (allergies, interfering symptoms, keeps appointments,
other)
g. Current prescription medications: (what kind, what for, dose, frequency, duration,
compliance)
h. Current over-the-counter medications and vitamins:
i.
Name of current primary physician:
2. FUNCTIONAL ASSESSMENT: Of Skills And Abilities To Manage Physical Illness:
(Indicate how the mental illness impacts this area)
(Recipient’s ability to manage medications, recognize and cope with symptoms, follow
treatment recommendations, behaviors/symptoms interfering with treatment, their acceptance
of illness, ability to communicate with providers, problem-solving skills).
MEDICAL TREATMENT PLAN:
Please provide any clinical recommendations and treatment directives that the patient needs to
have address.
Thank you for your assistance,
Matthew Smith
Executive Director