University of Maryland
Psychological Diagnostic Assessment
(Clinician to complete this document during session.)
Patient Name: _______________________________ DOB: Age: Sex:
Evaluation Date: Start time: End time:
Referred by: PCP:
Check box if evaluation is completed through telehealth.
Reason for Referral:
History of Present Illness
Depression: M ___ S ___ I___ G ___ E ___ C ___ A ___ P ___ S ___
Anxiety:
Trauma:
Sleep:
Eating:
Other:
Duration/course:
Frequency/intensity:
Functional Impairments:
Modifying Factors:
Mental Health Treatment History
PSY diagnoses (if any):
PSY meds:
Counseling (Type, Timeline, Outcome):
PSY hospitalizations:
Medical & Surgical History
Medical History:
Surgical History:
Treatment Regimen Factors:
Social History:
Family:
Current Living Situation:
Cultural considerations:
Other (finances, legal, etc):
MENTAL STATUS EXAMINATION
1=mild, 2=moderate, 3=severe
ORIENTATION Complete
Person
Place
Time
Purpose
MMSE Score (if any):
APPEARANCE
Dress Appropriate
Disheveled/dirty
Unusual/bizarre
Seductive
Meticulous/formal
Grooming Clean
Unclean
Unkempt
Meticulous/formal
Posture Appropriate
Hunched/slumped
Rigid/tense
Atypical
EYE CONTACT Appropriate
Staring/glaring
Avoidant
Fixed
MOTOR ACTIVITY
Appropriate
Overactive
Decreased/slowed
Restlessness
Tremor/tics
Repetitive Acts
Poor Coordination
AFFECT Appropriate
Full Range: Yes No
Sad/Depressed
Blunted/Flat
Fearful/Anxious
Euphoric/Elated
Angry
Labile
DEMEANOR Appropriate
Domineering
Hostile
Withdrawn
Tearful
Demanding/Needy
Dramatic
Agitated
Suspicious/Paranoid
Impulsive
Defensive
Manipulative
Overly Cooperative
Uncooperative
SPEECH
Rate Appropriate
Accelerated/fast
Decreased/slow
Quality Appropriate
Loud
Soft
Pressured
Slurred/Stammered
Disorganized
THOUGHT PROCESS
Appropriate
Perseveration
Tangential
Loose Associations
Flight of Ideas
Thought Blocking
THOUGHT CONTENT
Risk to Self/Others None
Suicidal Ideation
Suicidal Intent/Plan
Homicidal Ideation
Homicidal Intent/Plan
Assaultive Ideas/Plan
Perception None
Hallucinations
Delusions
Depersonalization
Derealization
Lost identity/Amnesia
“Lost time”
INTELLECT ESTIMATE
Superior
Above Average
Average
Below Average
Borderline
Extremely Low
Poor Knowledge Fund
Concrete Thinking
MEMORY PROBLEMS None
Poor Concentration
Poor Immediate
Poor short-term
Poor long-term
JUDGMENT Appropriate
Lacks Social Judgment
Lacks Personal Judgment
INSIGHT Appropriate
Minimizes problems
Denies problems
Blames others
SELF CONCEPT Balanced
Unrealistically Low
Unrealistically High
Substance Use (1st Use, Last Use, Heaviest Use, Current Amt/Freq, Route, Withdrawal)
Caffeine:
Tobacco:
Alcohol:
Cannabis: Opioids:
Other:
Obligation failure ____________________________
Use when hazardous __________________________
Legal problems ______________________________
Use despite problems
Taken greater/longer than intended
Unsuccessful efforts to quit
Abstinence Attempts:
Treatment:
Diagnostic Impressions
Mental Health: _______________________________________________________________________________
_______________________________________________________________________________
Personality: _______________________________________________________________________________
Medical:
Stressors:
Suicide Risk: None Low Moderate High
Homicide Risk: None Low Moderate High
Recommendations
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________
Referrals
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
Info for Medical Staff:
Examiner: Date:
Supervisor (if necessary): Date:
-----------------------
Notes:
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- university of maryland jobs baltimore
- university of maryland nursing jobs
- university of maryland hospital jobs
- university of maryland medical system careers
- university of maryland jobs
- university of maryland college park jobs
- university of maryland baltimore jobs
- university of maryland hospital baltimore
- university of maryland baltimore careers
- university of maryland jobs openings
- university of maryland hospital careers
- university of maryland baltimore county jobs