Академический Документы
Профессиональный Документы
Культура Документы
IDENTIFYING DATA Name: Interview Date/s: Address: _ Informant: _______________ Birthdate: ______________ _____________ Telephone: PATIENTS PRESENTING PROBLEM Patients statement of the problem: Onset and duration: Interval history: Reasons for seeking help: [a] [b] Current Status Patient medications: PERSONAL HEALTH HISTORY ILLNESS Diagnosis Data __ _ __ __ Marital Status: ______ Religion: _________ Nationality: Education: Gender:____ Age:
Occupation: ________________
Treatment
Date
ALLERGIES: Patient has no identified allergies TRAUMA: [ ] INCEST [ ] SPOUSE ABUSE [ ] BATTERY [ ] RAPE [ ] CHILD ABUSE
SOCIO-CULTURAL DIMENSION
A. Family/Significant Others
PATIENTS ENVIRONMENTAL SOCIOGRAM
B.Self-Concept
a.)IDEAL SELF realistic [ ] unrealistic b.)PERCEIVED SELF positive [ ] negative c.)SELF-ESTEEM (How much he likes himself ) average [ ] not much Who are you important to? Who are important to you? [ ] very much
[ ] [ ] [ ]
D.) Implications
Eating Pattern Pattern Sleeping Pattern [ ] Hypersomnia Self-care Status assist [ ] Fully dependent Lifestyle Past [ ] Fully dependent Present [ ] Fully dependent
[ ] Active [ ] Active [
Sexual Activity: Not assessed [ ] Active [ ] Normal Are you comfortable or satisfied with your sex life? [ ] NO Any other concern? [ ] STD [ ] Others
MILD
MODERATE
SEVERE
E. IMPLICATIONS
Intellectual Functioning Decreased level of consciousness Short attention span Concrete thinking Diminished calculation ability Diminished intelligence Orientation Orientation to person Orientation to place Orientation to time Insight Difficulty in acknowledging the presence of psychological problems Mostly blames others or circumstances for problems Judgment Difficulty in managing activities of daily living Difficulty in making reasonable life decisions Thought Content Obsession Compulsion Phobia De-realization/Depersonalization Delusion of grandeur Delusion of persecution Delusion of reference Delusion of influence Suicidal ideation Homicidal ideation Stream of Thought Associated distractions Thought flow decreased, slowed Thought flow increased Memory Impaired immediate recall Impaired recent memory
NOT PRESENT
MILD
MODERATE
SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
C. COMMUNICATION
Amplitude of Speech Increased, loud Decreased or slowed Atypical: high pitch, low pitch NOT PRESENT MILD MODERATE SEVERE
Content and Quality of Speech Word salad Neologisms Perseveration Jumping from one topic to another Atypical: slurring, stammering
NOT PRESENT
MILD
MODERATE
SEVERE
D.IMPLICATION
EMOTIONAL DIMENSION
Facial Expression Anxiety, fear, apprehension Depression, sadness Anger, hostility No variability in expression Increase lability of affect Affect inappropriate to thoughts Predominant Mood Blunted, absent, unvarying Anger, hostility Mania, euphoria Anxious, fearful, apprehensive Depression, sadness NOT PRESENT MILD MODERATE SEVERE
NOT PRESENT
MILD
MODERATE
SEVERE
IMPLICATIONS:
What is your concept of God? [ ] friend [ ] powerful [ ] judge [ ] teacher [ ] helper [ ] protector
[ ] caring, just
[ ] healer [] creator
What do you get from your religious practices? For example, in attending mass or liturgy, in going to confession, in forgiving self or others, in mediation or prayer, in helping the poor, in making sacrifice, in reading the Bible/Koran/ or any spiritual book, doing rituals and devotions to saints, or seeing a minister/ priest/ psychologist for spiritual counselling? [ ] sense of being made whole [ ] peace of mind [ ] feeling of being reconnected [ ] experience of being accepted by God and others [ ] strength to withstand problems [ ] reassuring feeling that Im doing what is right for me and my life in this world [ ] meaning [ ] guidance [ ] patience [ ] sense of direction and purpose [ ] a deep self-esteem grounded on the belief that God loves me [ ] the gift of grace of being forgiving, kind, respectful, non-judgmental to others [ ] the conviction that my life has contributed good things to others and the world [ ] self knowledge based on the values and faith I profess [ ] good health Tell me one experience in which you were incredibly grateful you have a God in your life. Or, tell me one instant or episode in your life in which God was powerfully present. Spiritual Distress Experience- the why my experience Experienced getting angry with God? Experienced feeling abandoned by God? [ ] yes [ ] yes [ ] no [ ] no
Believed youre so bad you cant get help from God? B. IMPLICATIONS
[ ] yes
[ ] no