Client History I.

GENERAL HISTORY OF CLIENT Name: MB Address: San Juan City Primary care provider: Brother Birth date: May 07, 1977 Nationality: Filipino Marital Status: Single Occupation: Sales Coordinator Religion : Roman Catholic English/Tagalog Chief Complaint: Behavioral Changes x 2 weeks Admitting Diagnosis: Behavioral Changes II. PRESENT PROBLEM A. When did you first notice the problem? B. What changes have you noticed?

Age: 35yo

Gender: Female

Educational Attainment: College Graduate Primary Language Spoken:

C. What do you think is causing the problem? III. RELEVANT HISTORY - FAMILY A. Family Configuration B. Family Dynamics C. Childhood and adolescence IV. RELEVANT HISTORY-PERSONAL A. Previous Hospitalization and illnesses B. Education Background C. Occupational Background D. Social and support system E. Marital Background F. Sexual Patterns G. Stressors/Losses H. Interest/abilities/pleasure I. Substance Use/abuse

"Nahihirapan akong matulog kasi every 30mins nagigising ako last 2weeks pa" as verbalized by the client. "Naging sobrang daldal ko at kung ano-ano sinasabi ko, at hindi nakikinig pag pinagsasabihan ng kapatid, madalas din akong hindi makatulog sa gabi kasi kinakausap ako ni god the father tuwing pinipikit ko mga mata ko." as verbalized by the client. "Nagkasabay sabay kasi yung stress ko sa family, work at sa lovelife" as verbalized by the client.

Anim kaming magkakapatid at panganay ako

magkkasundo kami at tulong tulong sa tuwing nagkakaproblema. as verbalized by the patient. "Magkakasundo naman kaming magkakapatid lalo na sa parents ko Admitted in UERM Psych Ward 1997 and 2006 due to Behavioral Changes College Graduate Recently promoted as sales coordinator Patient spends time alone instead of going out with friends and family Patient is Single Patient is sexually inactive Patient primary stressors are work, family and lovelife Patient loves to pray and singing videoke Patient is aware of drugs and has no record of substance abuse and drugs

J. Values and beliefs K. Cultural Influences Mental Status Exam A. Appearance and Motor Behavior B. Communication C. Thought process and content D. Mood and Affect E. Sensorium and Cognitive Ability F. Judgment and Insight G. Impulse and Control

Patient usually goes to church 4x a week. She does not believe to certain beliefs and practices Patient usually goes to the doctor whenever she need medicines Patient is appropriately dressed and fairly groomed. Has good hygiene and bathes daily. Maintains good eye contact without mannerisms. Cooperative and conversant with rapid spontaneous speech. Answers questions immediately and is very lively. Has religious delusions but no hallucinations. has tangentiality and flight of ideas. Patient has an appropriate affect and euthymic mood. Patient is awake and alert. Oriented to time, person and place with intact immediate, remote and recent memory. Patient can decide on her own and aware of behavioral changes noticed by her family and friends. Patient has poor to fail impulse control.