Patient File - Kevin Duncan

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CLINICAL RECORD FORM

ADMINISTRATIVE & SELF-REPORT INFORMATION (May Be Completed by Patient)

Patient: Kevin Silas Duncan Date of Birth: 12/12/XXXX Age: 25

Employer/School: Cobalt Hill

Sex: □ Male Marital Status: □ Single

Current Medical Conditions: None reported at this time.
Current Medications, Herbal Supplements & Vitamins (Daily Dose, Start Date, Name of Prescriber): Dietary Supplement.
Allergies/Adverse Reactions to Treatment: None reported.

Primary Care Physician Name: Dr. James Mallory PsyD., M.D.

Reason for Seeking Evaluation Today: General Check-Up/Evaluation.

CURRENT MENTAL STATUS EVALUATION: (Please check all that apply)


APPEARANCE: [X] Well-groomed [ ] Disheveled [ ] Bizarre [ ] Inappropriate

ATTITUDE: [X] Cooperative [ ] Guarded [ ] Suspicious [ ] Uncooperative
[ ] Belligerent [ ] Other ________________________________________________

MOTOR ACTIVITY: [X] Calm [ ] Hyperactive [ ] Agitated [ ] Tremors/Tics
[ ] Muscle spasms [ ] Other _________________________________________________

AFFECT: [X] Appropriate [ ] Labile [ ] Expansive [ ] Constricted
[ ] Blunted [ ] Flat [ ] Worrisome [ ] Sad [ ] Apathetic

MOOD: [X] Euthymic [ ] Depressed [ ] Anxious [ ] Euphoric [ ] Angry

SPEECH: [X] Normal [ ] Delayed [ ] Soft [ ] Loud [ ] Slurred
[ ] Excessive [ ] Pressured [ ] Incoherent [ ] Persevering

THOUGHT PROCESS: [X] Intact [ ] Circumstantial [ ] Tangential [ ] Flight of ideas
[ ] Loose associations
[ ] Other

THOUGHT CONTENT:

Hallucinations: [X] Not present [ ] Present
If Present, describe: ________________________________________________________

Delusions: [X] Not present [ ] Present
If Present, describe: ________________________________________________________



ORIENTATION: [X] Fully oriented [ ] Disoriented
If Disoriented, describe:_____________________________________________________


MEMORY: Long-Term [X] Intact [ ] Impaired
Short-Term [X] Intact [ ] Impaired
If Impaired, describe: ______________________________________________________

COGNITIVE FUNCTION:

General Knowledge: [X] Intact [ ] Somewhat intact [ ] Not intact
Serial Sevens/Calculations: [X] Intact [ ] Somewhat intact [ ] Not intact
Abstract Thinking: [X] Intact [ ] Somewhat intact [ ] Not intact

JUDGEMENT: [X] Intact [ ] Impaired – [ ] Mild [ ] Moderate [ ] Severe

INSIGHT: [X] Intact [ ] Impaired – [ ] Mild [ ] Moderate [ ] Severe

Suicidal Risk:
Suicidal Ideation? [ ] Yes [X] No
Current plan/intent to harm himself/herself? [ ] Yes [X] No
Hx of any previous attempts? [ ] Yes [X] No

Homicidal Risk:
Homicidal Ideation? [ ] Yes [X] No
Current plan/intent to harm others? [ ] Yes [X] No
Hx of any previous attempts to harm others? [ ] Yes [X] No

Legal Issues (Current and Past): Involuntary Manslaughter - Ruled Self-Defense
Other Risk Issues: None present at this time.

Structured Rating Scale Results:
If you use any standardized intstruments as part of your assessment, put your findings here. We suggest using instruments to complement your clinical assessment for depression (such as the PHQ-9: http://www.pfizer.com/phq-9/index.jsp ), Alcohol Disorders (such as the AUDIT: see http://www.niaaa.nih.gov and search on AUDIT for info), and Anxiety Disorders (such as Panic Disorder and Generalized Anxiety Disorder).

Depression Findings: __2__



Anxiety Findings: __ 0___



Alcohol Abuse/Dependence Findings ___0___

Treatment Plan
Specific Target Sx/Behaviors:N/A Interventions (Related to Goals): None Estimated Time for resolution: N/A


Patient found to be in good overall health. Advised to continue current line of self-care and follow up in 3 months.