SAMPLE BIOPSYCHOSOCIAL ASSESSMENT. Henry Ford Cottage Hospital. Date of Evaluation: Start Time: End Time:
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1 BIPSYCHSCIAL ASSESSMENT Date of Evaluation: Start Time: End Time: Informants: (check all) Patient Guardian Family ther Names: Circumstances of Admission (include vulnerability factors, prompting event, links to problem behavior and consequences): Psychiatric History: Information Unchanged from Intake Assessment No Previous Inpatient Treatment Previous treatment at HFCH Last Admission Date Inpatient History (when, where, LS, reason, outcome, follow-up compliance): utpatient History: Information Unchanged from Intake Assessment None Present: CMH HFHS utpatient Private Clinic: Therapist/Physician: Last seen: Medication compliant: Yes No Previous Treatment: (when, where, LS, reason, outcome, follow-up compliance): History of ECT None Yes Where: When: FRM #: HFCH MR-0110 page 1
2 BIPSYCHSCIAL ASSESSMENT Family Psychiatric History: Relationship Status: Never Married Married times Divorced Widowed Separated Partner Current Living Situation: Family/Friends: Children: None How Many & Ages: Reside with Patient: Yes No Sexual: Heterosexual Homosexual Bisexual Transgender ther Concerns: Support System/Community Resources: Education: Information Unchanged from Intake Assessment Highest Grade Completed: High School Graduate Special Education GED College Graduate-Degree: Employment: Information Unchanged from Intake Assessment Full Time Part Time Retired Disabled Student Homemaker Unemployed History (number of employers, longevity, etc) Military History: Information Unchanged from Intake Assessment None Yes-Non-Combat Yes Combat Years/Branch: Discharge Status: Honorable Dishonorable Spiritual Belief System: Non-active Active Identify Cultural: Fluent English Requires Interpreter-Language: ther accommodations (Diet, holidays, etc) Legal: Current Legal Involvement No Yes-explain: Probation Parole Incarcerations (explain): FRM #: HFCH MR-0110 page 2
3 BIPSYCHSCIAL ASSESSMENT Substance Abuse: Reviewed but does not apply Past History Current Use (month prior to admission) Circle and Complete as Applicable Age of First Use Age of Regular Use Max. Use, Dose and Frequency Last Month Prior to Admit. 48 hours Prior to Admit. Use Pattern Circle Route =ral S=Smoke IN=Inhalation Alcohol Heroin S IN IJ Methadone IJ ther piates: Diluadid, Darvon, xycontin S IN IJ Barbituratres: Tuinal Nembutal, Seconal Sedatives/hypnotics: Ambien, Lunesta, qualudes IJ Benzodiazepines Valium, Xanax, Klonopin GHB/GBL Cocaine Crack Cocaine S IN IJ Methamphetamine: Desoxyn S IN IJ ther Amphetamines: Dexadrine, Ritalln Hallucinagens: LSD, Mescaline IN IJ PCP S IN Marijuana, Hashish S Ecstasy: MDMA IN Ketamine: K, Cat S IN IJ Inhalants: glue, aerosols ver the counter IN IN Steroids: Durabolin, Stanozol IJ Caffine, Tobacco, Herbs FRM #: HFCH MR-0110 S IJ page 3
4 BIPSYCHSCIAL ASSESSMENT Primary drug of choice: Secondary drug of choice: Not Applicable Substance Abuse Related Symptoms (Check all the apply) Not Applicable ( ) Cravings ( ) Preoccupation ( ) Chest Pain ( ) Use upon Awakening ( ) Loss of Sensation in extremities/numbness ( ) Itching ( ) Compulsive Use ( ) Increased tolerance ( ) Paranoia ( ) Continued use despite negative consequences ( ) Anhedonia ( ) Mood swings ( ) Nausea/Vomiting ( ) Palpitations ( ) Abusive behavior toward others ( ) tremors ( ) Nose bleeds ( ) Loss of control once started ( ) Withdrawal signs after last use ( ) Blackouts ( ) Sinus problems ( ) Seizures ( ) Decline in hygiene ( ) Annoyed with others who complain about use ( ) Guilt associated with use ( ) Failed attempts at control Patient perception of alcohol/substance abuse as a problem? Yes No Not Applicable Describe: Family s perception of patient s alcohol/substance abuse: Not applicable Describe: Patient s longest period of abstinence: When did this occur? Identified factors contributing to abstinence: Not Applicable Substance Abuse Treatment History None Yes Previous Treatment: (when, where, LS, reason, outcome, follow-up compliance): Problems with betting money, lottery tickets or gambling None Yes Not applicable History of Self Help Groups: None AA NA GA ther: Describe: Finance: Employment Social Security Pension SSD SSI ther: Amount/Month: $ Amount Left: No Yes Amount Payee: $ FRM #: HFCH MR-0110 page 4
5 BIPSYCHSCIAL ASSESSMENT Mental Status and General Appearance Affect Wide Range Flat Constricted Blunted Tearful Congruent with Mood Incongruent with Mood Behavior Cooperative Uncooperative Pleasant Hostile Suspicious Restless Decreased inhibitions Guarded Hyper vigilant Evasive Demanding Passive Drowsy Poor Eye Contact Defensive Motor Mood Normal Posturing Shuffling Gait Agitated Retarded/Slow Tremors Tics Angry Irritable Subdued Euthymic Dysphoric Expansive Euphoric Depressed Anxious Labile Speech Normal Limited Loud Soft Rapid Slow Slurred Halting Thought PRCESS Stuttering Mute Monotone Pressured Goal Directed Spontaneous Tangential Circumstantial Flight of ideas Disorganized Blocking Loss associations Concrete Perseverations Examples: Thought CNTENT Normal Ideas of Hopelessness Ideas of Helplessness Poverty of Ideas Sexual Preoccupation Feelings of Unreality Guilt Indecision Compulsions bsessions Phobias Religiosity Grandiosity Auditory Hallucinations Visual Hallucinations lfactory Hallucinations Tactile Hallucinations Persecutory Delusions Delusions of Reference Delusions of Grandeur Somatic Delusions Paranoid Delusions Thought Broadcasting/Thought Insertion Examples: Concentration rientation Alert Poor Easily distracted Preoccupied Person Place Time Reason for evaluation Disorientation reported by Date of onset Describe Attention Marginal Intact Poor Measurement Judgement Good Fair Poor Describe FRM #: HFCH MR-0110 page 5
6 BIPSYCHSCIAL ASSESSMENT Insight Good Fair Partial Absent Describe Impulse Control Good Fair Poor Memory Problems Denied Short Term Long Term Date of onset Suicidal/Homicidal/Assaultive Risk Factors Denied Suicidal Ideation: Active Passive Command Has plans Has means Describe: Self Mutilation/Injury: No Yes: Homicidal Ideation: Active Passive Command Has Plans Specific Victim: Has Weapons Describe: Assaultive Behavior: No Yes: Readiness to Change That Will Prevent Readmission: Mental Health: Pre-contemplation Contemplation Preparation Action Substance Abuse: Pre-contemplation Contemplation Preparation Action Expectation of Treatment & Motivational Challenges to Ensure Aftercare Follow Through: Patient: Family: Clinical Impression (Summary): FRM #: HFCH MR-0110 page 6
7 BIPSYCHSCIAL ASSESSMENT Discharge Planning: Identification: Patient has Patient can get (with family or at home) Not Available Transportation: Patient s Ability and Capacity to Assist in Treatment & Active Discharge Planning: Good Fair Guarded Poor Upon discharge patient will return to previous living arrangements and Mental Health Provider so at this time there are no new identified barriers to discharge. Upon Discharge Patient Will Need Assistance with: NA Yes No Living Arrangements Marital or Family Stressors/Increasing Social Supports Educational or Employment Stressors Legal Concerns btaining or Changing Mental Health Providers Substance Abuse Providers/Support groups Financial Concerns Health Care Referral for Identification Assistance Agencies Safety Plan Current Abuse observable/assessed needing further assessment and intervention. Will need referral information. Recommendation/Action Plan: Initiate Group Therapy on Identified Circumstances for Admission 90 minute Group Therapy session. 60 minute Group Therapy session Due to the age, chronicity or acuity of the Patient s symptomatology this patient would not be expected to attain any clinical benefits beyond this time frame and may in fact be detrimental. Refer patient to: Red Blue Green Gray Track Patient will identify and begin to problem solve the above identified psychosocial stressors with the aid of the Social Worker. ther: Social Worker s Signature/Credentials Date Time FRM #: HFCH MR-0110 page 7
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