Professional Documents
Culture Documents
Name
Date of birth
Age
Gender
Age: Sex: Status:
Class
Date & Time:
Father name
Mother name
Address
Presenting complaints
School history
General assessment
Motor skills
Self help
Communication
Academic
Socialization
Name of Patient:
Name of Student:
I. PRESENTATION
A. GENERAL APPEARANCE:
B. GENERAL MOBILITY:
2. Activity:
( ) Normoactive
( ) Hyperactive/restless
( ) Agitated
( ) Psychomotor retardation
3. Facial Expression:
( ) Appropriate
( ) Inappropriate
Quantity
( ) Ecstatic ( ) Frightened
C. BEHAVIOR:
D. NURSE-PATIENT INTERACTION
( ) Cooperative
( ) Initially only
( ) Uncooperative
E. QUALITY
( ) Warm
( ) Distant ( ) Suspicious
( ) Talkative
( ) Hostile ( ) Others: ________
A. CHARACTER OF TALK
( ) Spontaneous ( ) Deliberate
B. ORGANIZATION OF TALK
( ) Relevant ( ) Irrelevant
C. ACCESSIBILITY
( ) Good
( ) Fair ( ) Self-absorbed
( ) Inaccessible
( ) Mute
( ) Poor
REACTION A. MOOD
B. AFFECT
( ) Appropriate ( ) Inappropriate
( ) Present ( ) Absent
D. SUICIDAL POTENTIAL
( ) Present
( ) Absent
E. HOMICIDAL POTENTIAL
( ) Present ( ) Absent
IV. THOUGHT PROCESS
A. PERCEPTIONS
Type:
( ) Present ( ) Absent
B. DELUSION
Type: ( ) Present
( ) Absent
C. IDEAS OF REFERENCE
( ) Present
( ) Absent
D. PREOCCUPATION AND RUMINATION
( ) Present ( ) Absent
( ) Present ( ) Absent
V. NEUROVEGETATIVE DYSFUNCTION
A. SLEEP
B. APPETTITE
( ) Increased
( ) Decreased
D. DIURNAL VARIATION
E. LIBIDO
F. ATTENTION SPAN
A. ORIENTATION
B. MEMORY
C. CALCULATION
( ) Good ( ) Fair
( ) Poor
D. GENERAL INFORMATION
( ) Unimpaired ( ) Impaired
( ) Unimpaired ( ) Impaired
VII.
JUDGMENT AND REASONING
( ) Unimpaired ( ) Impaired
VIII. INSIGHT
( ) Unimpaired ( ) Impaired
A. DISTURBANCE IN
( ) Presentation
( ) Stream of Talk
( ) Thought Content
( ) Neurovegetative Dysfunction
( ) Insight
B. DIAGNOSTIC CATEGORY
C. DSM IV DIAGNOSIS
Axis I
Axis II
Axis III
Axis IV
Axis V