Initial psychiatric screening.
|
Baker Act | Marchman Act | Ex-Parte | Voluntary
|
|
Initiated by: Judge | Police | Provider | Other
|
|
If police, specify department:
|
|
Appearance | Appropriate | Disheviled | Other
|
|
Mood | Appropriate | Angry | Sad | Manic | Other
|
|
Affect | Appropriate | Flat | Restricted Other
|
|
Motor Behavior | No Abnormalities Catatonic
|
|
Speech | Unremarkable Pressured Hesitant
|
|
Thought Process | Coherent Incoherent
|
|
Judgement/Insight | Adequate Fair Poor
|
|
AVH/Delusions | Present Not Present Other
|
|
Symptoms
|
History
|
|
Suicidal Threat/Attempt | Homicidal Threat/Attempt | Self-Inflicted Injury | Traumatic Event | Legal Court Order | Physician Order | Impulsive/Dangerous BehaviorPsychotic Features | Cognitive
|
Psychiatric Treatment/Hospitalization | ECT | Substance Abuse Treatment | No Previous Treatment
|
|
Marital Status
|
Current Living Arrangement
|
|
Single
|
House/Apartment/Homeless
|
|
Married
|
SNF or ALF?
|
|
Divorced
|
Lives with:
|
|
Other:
|
|
|
Active Abuse | Past History | No History
|
|
Substance:
|
|
Active | Early Remission | Sustained Remission
|
|
Route:
|
|
Frequency:
|
|
Yes
|
Physical | Sexual | Emotional
|
|
Traumatic event:
|
|
|
No
|
|
|
Symptoms
|
Promotion
|
|
Difficulty Falling Asleep
|
Relaxation Techniques
|
|
Difficulty Staying Asleep
|
Avoid Naps
|
|
Nightmares
|
Avoid Stimulants
|
|
Napping
|
Ear Plugs/Face Mask
|
|
Other:
|
Other:
|
|
History of Eating Disorder Yes | No
|
|
Weight Change in Last 3 Months Yes | No
|
|
Weight Change in Last 6 Months Yes | No
|
|
Intentional Weight Change Yes | No
|
|
Appetite Increased Yes | No
|
|
Appetite Decreased Yes | No
|
No comments yet.
Cheatography n. The art of mapping complex subjects into clear, instantly navigable reference guides.
