Mental Health Assessment Form PDF

EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Mental Heal...

EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Mental Health Assessment Form A. Demographic Profile Full Name: ____________________________________ Nickname: __________________________ Age: _____________ Sex : ______________ Date of Birth (MM/DD/YYYY): _____________ Address: ____________________________________________________________________________ Email Address: _______________________________ Contact number: __________________________ City/Town: _________________ Province: _____________________ Postal Code: ________________ Marital Status: _________________ Occupation: _________________ Ethnicity: __________________ Religion: ___________________ Health insurance/ Health card number: ________________________ Emergency Contact: NAME: _______________________ RELATIONSHIP: ___________ Contact No: __________________ B. Psychosocial Assessment Chief Concern What are the reasons why are you here today? __________________________________________________________________________________________ ______________________________________________________________________________ Psychiatric History Describe how are you feeling today: __________________________________________________________________________________________ ______________________________________________________________________________ Describe your mood as of the moment: __________________________________________________________________________________________ ______________________________________________________________________________ Have you experienced attending a counseling session before? (If yes, please specify what type and when) __________________________________________________________________________________________ ______________________________________________________________________________ Have you ever been hospitalized due to psychiatric condition? (If yes, please specify where and when) __________________________________________________________________________________________ ______________________________________________________________________________ QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Family History and Social History Where were you born and raised? ________________________________________________________ How do you describe your childhood? ___ Good / ___ Fair / ___ Poor / ___ N/A Were your parents ever divorced or separated? ___ Yes / ___ No If yes, how old are you that time ___ Who were your guardian(s)? _____________________________________________________________ Was there ever a time when your guardian(s) were someone other than your biological parents? ___ Yes / ___ No If yes, who _____________________________________________ How do you describe your relationship with your Mother ___ Good / ___ Fair / ___ Poor / ___ N/A How do you describe your relationship with your Father ___ Good / ___ Fair / ___ Poor / ___ N/A Additional comments: __________________________________________________________________ ____________________________________________________________________________________ How many brothers and sisters do you have? ___ Brother(s) ___ Sisters(s) ___ N/A Where are you in the birth order? _________________________________________________________ How do you describe your relationship with siblings growing up? __ Good / __ Fair / __ Poor / __ N/A Additional comments: __________________________________________________________________ ____________________________________________________________________________________ Currently, how are your relationships with your siblings? ___ Good / ___ Fair / ___ Poor / ___ N/A Additional comments: __________________________________________________________________ ____________________________________________________________________________________ Are your parents still living? ___ Yes / ___ No If no, describe circumstances and impact (including your age at the time of the death). _______________ __________________________________________________________________________________________ ______________________________________________________________________________ If your parents are still living, how do you describe your current relationship with them? ______________ __________________________________________________________________________________________ ______________________________________________________________________________ Additional comments: __________________________________________________________________ ____________________________________________________________________________________ Is there any known family history of mental illness or substance abuse? ___ Yes / ___ No If yes, describe impact on you: ___________________________________________________________ ____________________________________________________________________________________ Were there any cultural and/or social issues that impacted your childhood? ___ Yes / ___ No If yes, describe impact on you: ___________________________________________________________ ____________________________________________________________________________________ Describe financial situation of family during childhood: ________________________________________ ____________________________________________________________________________________ QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Is there anyone in your family member who has been treated for a psychiatric, emotional, or substance use disorder? ___ Yes / ___ No Family Member Relationship Diagnosis Type of Treatment (medication, counseling) 1. 2. 3. Can you describe how many medications you took (Medication Name, Dosage, Frequency, Side Effects, Was it beneficial to you?)? __________________________________________________________________________________________ __________________________________________________________________________________________ Have you taken any other medications in the past? Kindly describe those medications. (Medication Name, Dosage, Frequency, Side Effects, Was it beneficial to you?). __________________________________________________________________________________________ __________________________________________________________________________________________ Relationships Have you ever been married? ___ Yes / ___ No If yes, how many times? ___ Duration of marriages(s) _______________ Current marital status: _______________ If married, how do you describe your relationship with your spouse? __ Good / __ Fair / __ Poor / __ N/A Additional information: _________________________________________________________________ ____________________________________________________________________________________ If not married, are you currently in a relationship? ___ Yes / ___ No If yes, how long? _________ How do you describe your current relationship? ___ Good / ___ Fair / ___ Poor / ___ N/A Additional information: _________________________________________________________________ ____________________________________________________________________________________ Do you have any children? ___ Yes / ___ No If yes, list age and sex: ____________________ How do you describe your relationship with your children? ___ Good / ___ Fair / ___ Poor / ___ N/A Additional information: _________________________________________________________________ ____________________________________________________________________________________ Describe child custody or marital issues, if any: _____________________________________________ ____________________________________________________________________________________ Substance Use History Kindly fill up below all that applies. Leave it blank if not applicable. QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Substance Current First Use Last Use Method of Frequency Amount Use Age Age Use (Oral, Inhalation, Injection, Etc.) Alcohol Cocaine Crack Hallucinogen s (e.g. ecstacy) Heroin Inhalants (e.g., glue, gas, rugby etc.) Marijuana Methamphet amines (e.g. shabu) Opioids Nicotine Others: Spiritual and Cultural Assessment Are you raised in a religious faith? If yes, which one? _________________________________________ Are you a member of a religious faith? If yes, which one? ______________________________________ Do you believe in a higher power? ________________________________________________________ Do your spiritual beliefs provide you support? ___ Yes / ___ No Are there any specific cultural, ethnic, or religious beliefs/practices you would like to have considered in treatment? ___ Yes / ___ No If yes, kindly explain: ___________________________________________________________________ ____________________________________________________________________________________ Violence Risk Assessment Have you ever considered hurting yourself? If yes, please elaborate. _____________________________ ____________________________________________________________________________________ Has there been a previous suicide attempt? If yes, when? _____________________________________ ____________________________________________________________________________________ QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Do you intend to commit suicide? If yes, is there a means to carry out the plan? Is there intent to carry out the plan? ____________________________________________________________________________ __________________________________________________________________________________________ ______________________________________________________________________________ Do you have thoughts of harming others? If yes, who is the target? ______________________________ ____________________________________________________________________________________ Can these thoughts of harming others can be managed? ______________________________________ ____________________________________________________________________________________ Do you have the means to carry out a plan to harm others? If yes, is there intent to carry out the plan? __ __________________________________________________________________________________________ ______________________________________________________________________________ Do you have any risk behaviors such as self cutting, anorexia, bulimia, headbanging, or other self injurious behavior? ____________________________________________________________________ ____________________________________________________________________________________ Have you been hit, kicked, or otherwise physically harmed by another person in your past? _________ _____________________________________________________________________________________ Have you ever been forced to engage in sexual contact with which you were not comfortable? _________ ____________________________________________________________________________________ Have you ever been abused? If yes, describe by whom, when, and how. __________________________ ____________________________________________________________________________________ Coping Skills Kindly describe how do you cope with your situation in life or your environment: ____________________ ____________________________________________________________________________________ What are your current coping techniques: __________________________________________________ ____________________________________________________________________________________ Do you feel your current coping techniques work? ___ Yes / ___ No Any Comments/Concerns: ______________________________________________________________ ____________________________________________________________________________________ Interests and Abilities Activities you like to do in your free time: ___________________________________________________ ____________________________________________________________________________________ What are your hobbies and skills? ________________________________________________________ ____________________________________________________________________________________ What do you think are your personal strengths or positive qualities: ____________________________________________________ ____________________________________________________________________________________ What do you think are your personal weaknesses or negative qualities: ______________________________________________ ____________________________________________________________________________________ QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Client spends free time with: ___ Family / ___ Friends / ___ Co-Workers / ___ Alone / Other: _________ MENTAL STATUS CHECKLIST Status Criteria/ Instructions Remarks Appearance Hygiene Average Unclean Malodorous Clothing/Grooming Average, Appropriate Unkempt, Disheveled Atypical Gait Awkward Staggering Shuffling Rigid Trembling with intentional movement Trembling at rest Posture Slouched Relaxed Stiff Shaky Crouching Erect Behavior Automatisms Normal Tics Tremors Drumming finger Twisting of hairs and locks Tapping of foot Repetitive Actions Distinct Posturing Agitation Eye Contact Appropriate Sometimes Not appropriate Facial Expression Expressive Relaxed Fear Anxious QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Sadness Depression Unusual Atypical Attitude Attitude towards examiner Cooperative Calm Attentive Manipulative Suspicious Secretive Distracted Defensive Level of Awake Consciousness Alert Confused Disoriented Lethargic Orientation Time Time: Do you know what time it is? Yes Person: Can you state No your full name? Person Place: Do you know where Yes are we? No Circumstances: Do you know why are you here? Place Yes No Circumstances Yes No Speech and Speech Volume Ask the client to repeat the Language Loud following: “No ifs, ands, or Soft buts.” Monotone Speech Rate Appropriate, controlled Rapid, pressured Slow Monotonous QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Speech Quantity Talkative Expansive Paucity Poverty Fluency Slurred Clear Hesitant With good articulation Language Neologisms (forms new words) Anomia (difficulty naming objects) Word salad (speech is incomprehensible) Clang associations (meaningless word rhymes) Echolalia (repeat noises and words that they hear) Apraxia (has trouble saying what they want to say) Aphasia (speech is damaged) Mood and Affect Mood (Subjective) Mood Angry a. How are you Irritable feeling at this moment? Anxious Restricted Depressed Guilty Brightly Elevated Mood Darkly Elevated Mood Other:__________ Affect (Objective) Appropriate Affect: reacts with the proper and expected emotion for the situation. Inappropriate Affect: displaying emotion or expressions that QF-PQM-035 (05.03.2023) Rev.06 EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING are not congruent with the situation. Blunted Affect: showing little or a slow-to-respond facial expression. Broad Affect: displays a full range of emotional expression. Flat affect: no facial expression. Restricted Affect: one type of expression, serious or somber. Labile Affect: rapid shifts in the expression of feelings. Constricted Affect: decreased ability to express emotion through facial expressions, tone of voice, and physical movements. Apathetic Affect: having or showing little or no feeling or emotion. Congruent Affect: QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Physiologic and Eating habits and Self-care behaviors Considerations Normal eating appetite Emotional under-eating Emotional overeating Sleep Average hours of Sleep:______ Sleep patterns Normal Sleep Has difficulty in falling asleep Has difficulty in staying asleep Wakes up too early Unrefreshing or non-restorative There is presence of nightmares Limitations in performing ADL Washing Toileting Dressing Feeding Mobility Transferring Memory Immediate Memory Immediate Memory Average a. Ask the client to Below Average remember three words (e.g. blue, No data table, horse) and have them repeat Recent Memory (Recent to you after 5 past or day/month) minutes. Average Below Average Recent Memory No Data a. Ask the client about your name (examiner’s name). b. Did you take any medications today? What are those Remote memory: medications? Childhood or past Hx c. Are you aware Average about the cause of Below Average the recent lockdowns we No Data have experienced? d. Do you know when the pandemic started? QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Remote memory a. What is your favorite childhood memory? b. What year did you finish your study? Insight Can recognize one’s Interpretation strength and limitations Good - client has FULL Good Insight awareness of one’s Fair Insight strengths, limitations, and conditions. Poor Insight Fair - client has SOME Can recognize illness and awareness of one’s own need for treatment strengths, limitations, and Good Insight conditions. Fair Insight Poor Insight Poor - client has LITTLE to NO awareness of one’s strengths, limitations, and conditions. Judgment Questions for assessing Good judgment judgment: Fair judgment a. If you found a Poor judgment wallet on the floor, what would you do? Interpretation Good - client’s answer is based on an ACCEPTABLE BEHAVIOR IN SOCIETY. Fair - client’s answer is based on a SLIGHTLY ACCEPTABLE BEHAVIOR IN SOCIETY. Poor - client’s answer is NOT AN ACCEPTABLE BEHAVIOR IN SOCIETY. Suicidal and Suicidality Questions: Homicidal None Suicidality Ideation a. Do you ever feel that life isn’t worth Plan living? Or that you Intent would just as soon Self harm be dead? b. Have you ever Homicidality thought of harming None yourself? How? Aggressive Intent Homicidality a. Do you think about Plan hurting others with QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING people who have wronged you? b. Have you had desires to hurt others? If so, how? Average Thought Process Overabundance (Observed) Paucity Spontaneous Needs prompting Mixed Goal Directed, Logical Perceptive Relevant-irrelevant to question asked Loose associations, Rambling Perseveration or repetition of thoughts Effort to go from thought to thought Tangential Preoccupation Preoccupation Thought Content Obsessions Questions: Compulsions a. What’s been on your mind lately? Phobias, Paranoia, Have you had any Persecution recent obsessions Wanting to harm or phobias? Can self you describe Wanting to harm them? others b. Have you ever thought of harming Somatic Concerns yourself or others? Repetitive thoughts-worry Somatic Concerns: a. Have you ever had any worries that Thought Disturbances you might be sick? Delusions (False beliefs) Repetitive thoughts-worry Ideas of reference questions: Thought a. Are you worried, broadcasting scared, or Magical thinking frightened about Confabulation something? (honest lying) Grandiosity Thought Disturbances Delusions Hallucinations a. Do you have any None personal beliefs that are not shared Auditory by others? Visual QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Olfactory Ideas of reference Gustatory a. Do things sometimes seem Illusions unnatural to you? (Do you feel like None the TV is Present sometimes talking to you personally?) Depersonalization None Thought broadcasting Present a. Does it ever seem like people are Derealization stealing your None thoughts, or Present perhaps inserting thoughts into your head? Does it ever seem like your own thoughts are broadcast out loud? Magical Thinking a. Do things seem unnatural/unreal to you? Hallucinations: a. Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things that are not really there, such as voices or visions? Illusions a. Do you sometimes misinterpret real things that are around you, such as muffled noises or shadows? Depersonalization a. Do you sometimes feel detached from yourself especially when you are experiencing anxiety? Derealization a. Do you sometimes feel detached from your environment? Attention Attention/Distractibility Instruct the client to: Sufficient a. Repeat the days of Deficient the week backwards QF-PQM-035 (05.03.2023) Rev.06  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Easily distractible b. Spell the word Short attention “hotdog” span backwards c. Begin from 50 then Ability to Concentrate subtract 7 again and again and so Sustained on Selected Divided Intellectual Abilities Information and Information Information Questions vocabulary Good a. Name the current Average president, vice president, and Poor mayor. No Data b. Name 5 cities located in Cavite. Vocabulary Grade school level High school Level Fluent Consistent with education Abstraction Abstraction Abstract thinking a. Similarities Similarities (how are the Good following items Average similar?) Apple and orange? Poor Chair and table? No data b. Proverbs ( how would you describe Proverbs the following Literal saying? Deep 1. Ang hindi lumingon sa pinanggali ngan, ay di makakarati ng sa paroroona n. 2. Kapag binato ka ng bato batuhin mo ng tinapay 3. Pag may tiyaga may nilaga. Name of Examiner: _____________________________________ Signature: ____________________ Date of examination: __________________ QF-PQM-035 (05.03.2023) Rev.06