You are on page 1of 9
(¢ St.Thomas Elgin General Hospital EMERGENCY PSYCHIATRIC ASS! ESSMENT Clenierency Consult ison CO Urgent Clinic O other: DATE: GrGtenkgnfn. TIME 73 SSQURCE: iEFERRAL agenesis Sylar, Suppo Ssiom. © Involuntary Status at time Brie Consider the following: EP Marta status consider the Following: sires Enforcoment ily of Referral: MRN# SEzs8194 ENCH 420100466 High, Jamie David pop 1974/10/07 Sex: M [— Fam, Physi SENOS FO eerie Liem Oren one ving Arrangements horeobe sf . Typect Residence Ouellet, Tracy Lara piensa MEDICATION HISTORY: (ore, Netea soe etestion History Form AC eM no FICona % UiGcen 2 Qua hi O modication History Form Reviewed eg WS 2 Tore Psychiatric Assessment (continued) Patient's Name FAMILY PSYCHIATRIC: (and gonogram if helpful) ZOO: ———— ae CuCl eee ott Smoking: Bay aro =AaA= = es Alcohol: Se SES tied Curent witawa symptoms lic Drug Use: Oe Bata oes CcurerPest withdrawal symptoms = mo Treatment History: 7 SIGNIFICANT LIFE EVENTS / SOCIAL HISTORY / TRANSITIONS Ely Cheoad E en ean poy sty Touma /Lent Sa Garibling eee eaten ee en ict. chistory oy sexual violence) (ee Chere atT (COMPLETE RELEVANT OATA ONLY. LEAVE Al OTHERS BLANK. ra FERS ae eee! Pe eee ene ES ® C)sttThomas Elgin General Hospital PSYCHIATRIC ASSESSMENT a Continued NOV t9 205 Impairment, savere impalement) istetine Eictony ot cadekle tines © 2 71a eure EEE] Engaged in self injurious behaviour without stated or obvious suicide intent{Specity recent or remote) Prete gpcors or deterrents to suicide = ch lolses) O16 paty tt IDAL / HOMICIDAL IDEATION: (current suicide plan(s)) VIOLENCE/ AGGRESSION TO OTHERS: = History of volenoe in hospital Ree tyes Violence to othersiproperiy io [Yes Intimidation‘of othersithreats “ LJ No [}Yes Violet ideation No Dyes = Than, FA, liscerce| ACCESSTOFIREARMS: J eos eee cud wre at or to.) APPEARANCE AND BFHAVIOURS: {isss, apeming, supig, siting, motor getvy) = ae Ao Le bbe Het fx 4 SPEEGHE: (tne atonoy,prespured,incoheron) = ¥Leegk De ea AFFECT! BOD: fit, denypsse Ile, inaporopiat eat, suspcous) THOUGHT FORM: (iliogical, flight of ideas, loosening of associations, blocking) ee KOO! . PERCEPTUAL ABNORMALITY: (hallucination, ilusion, ete) 71 ay COGNITIVE FUNCTION; (orientation concenipstign, memory) Wy Fe wow MeRTAL STAT See ea Ded AP ere RO F + 7 on fame 3 lect fel 7a werd J ODEMENT; iy mange hpyeutaofipheractons) = a eace, INSIGHT: (appreciation of nature and severity of illness) Ate | ie Satine By eenaene erat tvaxso) Tore