Evaluation Patient
Title:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Demonstrate:
CC:
HPI:
Pertinent historical past in file and from patient: X
For the duration of assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears to be like beautiful, no reported feelings of excessive guilt,
no reported anhedonia, does now not file sleep disturbance, does now not file exchange in appetite, does now not file libido disturbances, does now not file exchange in vitality,
no reported changes in concentration or memory.
Patient does now not file elevated job, agitation, menace-taking behaviors, compelled speech, or euphoria. Patient does now not file excessive fears, worries or awe attacks.
Patient does now not file hallucinations, delusions, obsessions or compulsions. Patient’s job stage, consideration and concentration were seen to be within usual limits. Patient does now not file symptoms of ingesting disorder. There is now not this type of thing as a most modern weight reduction or make. Patient does now not file symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies sinister/illegal behaviors.
Hypersensitive reactions: NKDFA.
(medication & meals)
Previous Medical Hx:
Medical historical past: Denies cardiac, respiratory, endocrine and neurological considerations, at the side of historical past head fracture.
Patient denies historical past of power infection, at the side of MRSA, TB, HIV and Hep C.
Surgical historical past no surgical historical past reported
Previous Psychiatric Hx:
Earlier psychiatric diagnoses: none reported.
Describes staunch route of illness.
Earlier medication trials: none reported.
Safety considerations:
Historical past of Violence to Self: none reported
Historical past of Violence t o Others: none reported
Auditory Hallucinations:
Visible Hallucinations:
Psychological neatly being therapy historical past discussed:
Historical past of outpatient therapy: now not reported
Earlier psychiatric hospitalizations: now not reported
Prior substance abuse therapy: now not reported
Trauma historical past: Client does now not file historical past of trauma at the side of abuse, home violence, witnessing demanding occasions.
Substance Exhaust: Client denies exhaust or dependence on nicotine/tobacco merchandise.
Client does now not file abuse of or dependence on ETOH, and different illicit medication.
Most recent Medications: No most modern medications.
(Contraceptives):
Dietary supplements:
Previous Psych Med Trials:
Household Medical Hx:
Household Psychiatric Hx:
Substance exhaust
Suicides
Psychiatric diagnoses/hospitalization
Developmental diagnoses
Social Historical past:
Occupational Historical past: currently unemployed. Denies previous occupational hx
Militia provider Historical past: Denies previous militia hx.
Training historical past: accomplished HS and vocational certificate
Developmental Historical past: no essential miniature print reported.
(Childhood Historical past embody in utero if accessible)
Upright Historical past: no reported/identified honest considerations, no reported/identified conservator or guardian.
Non secular/Cultural Concerns: none reported.
ROS:
Constitutional: No file of fever or weight reduction.
Eyes: No file of acute vision changes or take into fable distress.
ENT: No file of listening to changes or scenario swallowing.
Cardiac: No file of chest distress, edema or orthopnea.
Respiratory: Denies dyspnea, cough or wheeze.
GI: No file of abdominal distress.
GU: No file of dysuria or hematuria.
Musculoskeletal: No file of joint distress or swelling.
Pores and skin: No file of rash, lesion, abrasions.
Neurologic: No file of seizures, blackout, numbness or focal weakness. Endocrine: No file of polyuria or polydipsia.
Hematologic: No file of blood clots or easy bleeding.
Hypersensitivity: No file of hives or allergy.
Reproductive: No file of grand considerations. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, and many others…)
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