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

  1. Recommendations: 

 

  1. 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

  1. Understanding, Motivation, and Compliance: 

 

  1. Psychological Formulation: 

 

CC:        
xxxxx
xxxxx

 

 

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