Initial Evaluation Template

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Transcription:

Demographic Information (Please complete all questions on this form) Member Name: Date: Name: Address: Phone (Home): Phone (Work): Date of Birth: Social Security #: Guardianship (for children and adults when applicable): Marital Status (check one): Race (optional): [] Never Married [] Divorced [] White [] Native American [] Married [] Separated [] African-American [] Asian [] Widowed [] Cohabiting [] Hispanic [] Other Gender: [] Male [] Female Age: Family Members: Name Age Gender Relationship Employer: Occupation: School (for children, and adults when applicable): Referral Source: Insurance Information: Insurance Company/HMO: Phone: Member ID#: Managed Care Company: Claims Address: Phone: Emergency Information: Primary Care Physician: Phone: Name of Emergency Contact: Phone: Relationship to Patient: Source of Information: (patient, family, other): 2017 Magellan Health, Inc. rev. 11/17 Page 1

Presenting Problem (include onset, duration, and intensity): Precipitating Event (why treatment now): Mental Status (circle appropriate items): Appearance: Appropriate Inappropriate Disheveled Unclean Bizarre Affect: Appropriate Inappropriate (describe): (sad, angry, anxious, superficial, restricted, labile, flat) Orientation: Oriented Disoriented to person, place, time, date, day, situation Mood: Normal Other (euthymic, depressed, irritable, angry) Thought Content: Appropriate Inappropriate Thought Process: Logical Tangential Illogical Speech: Normal Slurred Slow Pressured Loud Motor: Normal Excessive Slow Other Intellect: Average Above Below Insight: Present Partially Present Absent Judgment: Normal Impaired Impulse Control: Normal Impaired Memory: Normal Impaired: Immediate Recent Remote Concentration: Normal Impaired Attention: Normal Impaired Behavior: Appropriate Inappropriate (anxious, agitated, guarded, hostile, drowsy, cooperative, hyperactive, psychomotor retarded) Thought Disorder: No Problem Grandiosity Paranoia Delusions Tangential Loose Associations Ideas of reference Confusion Thought Blocking Perseveration Flight of Ideas Hallucinations Obsessions Brain Injury Phobias Previous Medical History: Allergies (adverse reactions to medications/food/etc.): PCP Name and Telephone Number: Date of Last Physical Exam: Findings from Exam: Any relevant medical conditions (diabetes, hypertension, head traumas, cardiac problems, asthma or other breathing problems, cancer, etc.): 2017 Magellan Health, Inc. rev. 11/17 Page 2

Family Medical History: Current Medications (Include prescribed dosages, dates of initial prescription and refills, and name of doctor prescribing medication): Hospitalizations/Surgeries (include dates, complications, adverse reactions to anesthesia, outcomes, etc.): Past Psychiatric History (Mental Health and Chemical Dependency): Hospitalizations: Family History of Suicide/Homicide: Yes No Prior Outpatient Therapy: Previous practitioners and dates of treatment: Previous treatment interventions: Response to treatment interventions including medications: Results of recent lab tests and consultation reports: Family Mental Health or Chemical Dependency History: Psychosocial Information: Support Systems: School/Work Life: Marital History: Legal History: Military History: Spiritual Beliefs: 2017 Magellan Health, Inc. rev. 11/17 Page 3

Ideations Suicidal Ideation Homicidal Ideation None Noted Thoughts Only Risk Assessment Plan Intent (describe) (describe) Means (describe) Attempt (describe) History (Ideation and/or Attempts) Substance Abuse History (complete for all patients age 12 and over) Substance Amount Frequency Duration First Use Last Use Caffeine Tobacco Alcohol Marijuana Opioids/ Narcotics Amphetamines Cocaine Hallucinogens Others: Children and Adolescents Only: Developmental History (developmental milestones met early, late, normal): Peri-natal History (details of pregnancy/labor/delivery): Pre-natal History (medical problems during pregnancy, mother s use of medications): Risk Factors to include: Non-compliance with treatment AMA/elopement potential Prior behavioral health inpatient admissions History of multiple behavioral diagnosis Suicidal/homicidal ideation Domestic Violence Child Abuse Sexual Abuse Eating Disorder Other (describe) Strengths: 2017 Magellan Health, Inc. rev. 11/17 Page 4

Barriers: Diagnostic Impression: Axis I/ICD-10: Axis III: Medication Education (as appropriate): Yes N/A Patient Verbalizes Understanding Diagnosis Education (as appropriate): Yes N/A Patient Verbalizes Understanding Follow-up Appointment: Clinician Signature: Date: 2017 Magellan Health, Inc. rev. 11/17 Page 5

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