Initial Evaluation Template - Magellan Provider
[Pages:5]Initial Evaluation Template
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):
[] Never Married [] Divorced
[] Married
[] Separated
[] Widowed
[] Cohabiting
Race (optional): [] White [] African-American [] Hispanic
[] Native American [] Asian [] Other
Gender:
[] Male
Age: ___________
[] Female
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
Initial Evaluation Template
Presenting Problem (include onset, duration, and intensity): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Precipitating Event (why treatment now):___________________________________________ ______________________________________________________________________________
Mental Status (circle appropriate items):
Appearance: Affect:
Appropriate Appropriate
Orientation:
Oriented
Mood:
Normal
Thought Content: Appropriate
Thought Process: Logical
Speech:
Normal
Motor:
Normal
Intellect:
Average
Insight:
Present
Judgment:
Normal
Impulse Control: Normal
Memory:
Normal
Concentration: Normal
Attention:
Normal
Behavior:
Appropriate
Inappropriate Disheveled Unclean Bizarre
Inappropriate (describe):__________________
(sad, angry, anxious, superficial, restricted, labile, flat)
Disoriented to person, place, time, date, day, situation
Other________ (euthymic, depressed, irritable, angry)
Inappropriate
Tangential
Illogical
Slurred
Slow
Pressured
Loud
Excessive
Slow
Other________
Above
Below
Partially Present Absent
Impaired
Impaired
Impaired:
Immediate Recent
Remote
Impaired
Impaired
Inappropriate (anxious, agitated, guarded, hostile, drowsy,
cooperative, hyperactive, psychomotor retarded)
Thought Disorder: No Problem Delusions Ideas of reference Perseveration Obsessions
Grandiosity Tangential Confusion Flight of Ideas Brain Injury
Paranoia Loose Associations Thought Blocking Hallucinations 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
Initial Evaluation Template
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
Initial Evaluation Template
Ideations
None Thoughts Noted Only
Risk Assessment
Plan
Intent
Means
(describe) (describe) (describe)
Attempt (describe)
Suicidal Ideation Homicidal Ideation
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
Initial Evaluation Template
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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