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What Are the Client’s Current Psychiatric and Nonpsychiatric Medications?

What Are the Client’s Current Psychiatric and Nonpsychiatric Medications?

What Are the Client’s Current Psychiatric and Nonpsychiatric Medications?
Assignment: CURRENT LIVING SITUATION

Living Situation

Dependents/Care for Dependents Employment/Disability/Seeking Disability Income/Source of Income

Insurance Transportation Daily Living Skills

Social/Leisure Activities

Available Social Support

BIRTH AND DEVELOPMENTAL HISTORY

A. PRENATAL/BIRTH/DEVELOPMENT

Pregnancy and Labor Developmental Milestone(s)

B. EARLY CHILDHOOD

Family of Origin—Parents/Siblings/Extended Family, as Relevant

Geographic/Cultural/Spiritual Factors/as Relevant

Abuse/Trauma History

Physical/Emotional/Sexual Abuse History

SCHOOL AND SOCIAL RELATIONSHIPS

This section should include information about social supports and the nature of those relationships; include current friendships, school/peer group experience, and military history, if applicable.

A. SOCIAL DEVELOPMENT

Cultural/Peer Group/Environment School

Adolescence

B. EDUCATIONAL HISTORY

Public or Private School(s) Where Attended

Performance

Educational Level

Extracurricular Activities

C. MILITARY HISTORY What Branch

Duty Assignment (when/where) Rank/Discharge

FAMILY MEMBERS AND RELATIONSHIPS

A. SIGNIFICANT FAMILY RELATIONSHIPS

Family member and relationship

Relationship dynamics

B. INTERPERSONAL/MARITAL HISTORY

Age of Involvement in Relationships

Sexual Orientation

Length of Relationships

Relationship Patterns/Problems

Partner’s Age/Occupation

HEALTH AND MEDICAL ISSUES

A. MEDICAL HISTORY/HEALTH STATUS

History of Traumatic Injuries/Illnesses/Chronic Health Problems

Describe Current Illness

Is Client in Good General Health?

Is Client Allergic to Any Medications? Who Is Client’s Primary Care Physician?

Is the Client Being Treated by Any Other Physician(s)?

What Are the Client’s Current Psychiatric and Nonpsychiatric Medications?

Describe Client’s Health Habits: Appetite, Sleep, Exercise, Nicotine, Alcohol, Illicit Drugs, and Vitamins/Herbal Supplements?

Sexual Functioning: Preference/Problems

Pregnancy/Birth Control

Risk Behaviors for STDs

B. MENTAL STATUS

Attitude/Appearance/Behavior Affect/Mood/Psychomotor Activity

Orientation/Memory/Cognition Thought Process/Content Speech

Insight/Judgment Homicidal/Suicidal Ideation Hallucination(s)/Delusion(s)

C. HISTORY OF PSYCHIATRIC ILLNESS AND PREVIOUS TREATMENT

Previous Diagnoses/Medications/Inpatient and Outpatient Treatment History of Suicidal Ideation/Suicide Attempts/Self-Mutilation/Homicidal Ideation/Aggression

E. SUBSTANCE ABUSE HISTORY

Type/Onset/Duration/Amount Frequency/Pattern of Use Involvement in Treatment

SPIRITUAL DEVELOPMENT

Religion/spirituality

SOCIAL, COMMUNITY, AND RECREATIONAL ACTIVITIES

CLIENT STRENGTHS, CAPACITIES AND RESOURCES

Cultural/ethnic factors

Personal strengths

Family/social resources

OTHER SIGNIFICANT FACTORS

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