The document is a psychiatric assessment form for a client presenting with major depression. It contains sections to document the client's presenting issues, past psychiatric and medical history, social history, review of symptoms, mental status examination, suicide potential assessment, and proposed DSM classification. The form guides the collection of information on the client's perception of their problem, current symptoms and triggers, treatment history, and other relevant details to evaluate their condition and develop a treatment plan.
The document is a psychiatric assessment form for a client presenting with major depression. It contains sections to document the client's presenting issues, past psychiatric and medical history, social history, review of symptoms, mental status examination, suicide potential assessment, and proposed DSM classification. The form guides the collection of information on the client's perception of their problem, current symptoms and triggers, treatment history, and other relevant details to evaluate their condition and develop a treatment plan.
The document is a psychiatric assessment form for a client presenting with major depression. It contains sections to document the client's presenting issues, past psychiatric and medical history, social history, review of symptoms, mental status examination, suicide potential assessment, and proposed DSM classification. The form guides the collection of information on the client's perception of their problem, current symptoms and triggers, treatment history, and other relevant details to evaluate their condition and develop a treatment plan.
School of Allied Health & Nursing BACHE!" !# SC$ENCE $N NU"S$N% NU" &''() *ENTA HEATH NU"S$N% The Interview and Assessment Process PSYCHIATRIC DIAGNOSIS: MAJOR DEPRESSION Clients Initials: _________ Age:_________ Date:_____________ Marital Status:___________ +"ESENT $NESS Clients Perception of Problem Current Symptoms Precipitating Factors Current Treatment Allergies Substance Use +AST $NESS Psychiatric Meical Family !istory Personal " Social !istory Se#ual !istory "E,$E- !# S.STE*S $espiratory Cario%ascular &astrointestinal Urogenital Se#uality Sleep " $est *ENTA STATUS E/A*$NAT$!N Appearance " 'eha%iour (e%el of Consciousness Posture " Motor Mo%ements Dress " &rooming Moo Affect: Flat ___ 'lunte___ Sa___ !appy___ )late___ An#ious___ Incongruent___ Speech Thought Process Thought Content Perceptions Insight *ugment Cogniti%e Functions (memory, attention & concentration, a!tract rea!onin"# SU$C$0E +!TENT$A Ieas Current Past Plans If +es, Specify Intentions Access to Means Attempts $ecent Past Alcohol-Drugs Panic Attac.s Family !istory !omicial Ieation Cultural Issues Spiritual Issues 0S*1$, CASS$#$CAT$!N A/IS I A/IS II A/IS III A/IS I0 A/IS 0