Health And Behavior Assessment Transcript
NAME: xxxxxxxxx
DOB: mm/dd/yy
EVALUATION SESSIONS: mm/dd/yy, mm/dd/yy
PSYCHOLOGICAL TESTING: mm/dd/yy
REPORT DATE: mm/dd/yy
Height: x’ x” |
Reported Weight: xxx lbs |
BMI: xx |
Anticipated Weight: xx to xx lbs |
IDENTIFYING DATA:
REASON FOR PURSUING SURGERY:
DIAGNOSTIC IMPRESSIONS:
Axis I – Clinical Disorders:
Axis II – Personality Disorders:
Axis III – Medical Conditions, by patient report:
Axis IV – Reported Psychosocial and Environmental Problems/Stressors:
Axis V – Global Assessment of Psychosocial and Occupational Functioning on a continuum of mental health (not physical health):
CONCLUSIONS
- Recommendations:
- Current Treatment Plan and Aftercare Plan: .
Special Needs or Precautions:
HISTORY OF PRESENTING ILLNESS:
Previous Attempts at Disease Management:
Faulty Cognitions and Misattributions:
Eating Disorder-Related Behaviors:
Self-Esteem:
MASTERY OF BEHAVIORAL GUIDELINES FOR DISEASE MANAGEMENT
Day and Night Routine:
Boundaries and Limit Setting:
Self-Care and Treatment Adherence:
SUBSTANCE USE
OTC and Prescription Medications:
Nicotine:
Alcohol:
Illicit Substances:
Stress Management and Coping Skills:
Other Impulsive/Compulsive Tendencies:
Physical and Leisure Time Activities:
TYPICAL EATING PATTERN AND FLUID INTAKE:
PSYCHIATRIC HISTORY:
MEDICAL HISTORY
Allergies/Sensitivities:
Prenatal Complications, Birth Trauma, Unusual Birth Weight:
Head Trauma, Concussion, Extremely High Fevers, Seizures:
Thyroid Function: .
Hospitalizations and Surgeries:
Current Medications:
Vitamins/Supplements:
Family Planning:
Activities of Daily Living (ADLs):
Attitudes, Fears, or Concerns Regarding this Surgery:
FAMILY HISTORY
Medical:
Psychiatric/Substance Abuse:
SOCIAL AND DEVELOPMENTAL HISTORY:
Traumatic Life Events and Abuse/Neglect history:
Educational History:
Current Living Situation, Partner, and Children:
Religious Orientation:
TWO YEAR GOALS:
PSYCHOLOGICAL TESTING:
MENTAL STATUS:
Self-Perception of Readiness for Surgery:
SUMMARY OF CURRENT FINDINGS:
- Understanding, Motivation, and Compliance:
- Psychological Formulation:
CC:
xxxxx
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