23 Oct Assessment Report for
for
Personality Assessment
Date:
To:
From:
Re:
History and Description of Primary Complaint and Current Related Symptoms
Who Referred
For
Etiology
Symptom Duration
Activity Scale
Assessment Instruments (examples)
Clinical Interview Minn. Multiphasic Pers. Inventory (MMPI-2)
Beck Depression Inventory (BDI) Zung Depression Inventory (ZDI)
Brief Battery for Health Improvement-2 (BBHI2) Multidimensional Pain Inventory (MPI)
Battery for Health Improvement-2 (BHI2) Beery VMI
Mini-Mental Status Exam (MMSE) Repeatable Battery for Neuropsychological Functioning (RBANS)
Seven Minute Screen for Dementia Substance Abuse Subtle Screen. Inv. (SASSI-3)
Millon Clin. Multiaxial Inven. (MCMI-III) Validity Indicator Profile (VPI)
Dementia Rating Scale-2 (DSR2) Halstead-Raitan Neuropsychological Battery (HRB)
Luria-Nebraska (LNB) Millon Behavioral Medicine Diagnostic (MBMD)
Multidimensional Health Locus Wechsler Adult Intelligence Scale
Of Control Wechsler Intelligence Scale for Children
Presentation
Orientation?
Affect?
Appearance? Dress _____ Hygiene _____
Speech
Memory/cognitive deficit
Psychosis:______Thought disorder_________Uncontrolled mood disorder.
Previous Medical Treatment for Complaint
Physicians
Procedures
Medications
Life Disruption From Present Symptoms
Work
Family
Avocational
Sleep
Appetitie
Commonly Used Coping Mechanisms
Physical pain and discomfort
Affective discomfort and suffering
Any Possible Secondary Gain Issues?
Litigation
Workman’s Compensation
Disability
Addiction Potential
Does this patient drink – How much/frequently? Any legal (DUI) or social (fights with family) about drinking? Does the client use illicit drugs? How much/frequently? What prescription meds? Ever felt “out of control” on the meds? Ever run out of controlled meds early? Has a doctor ever decided not to refill meds
General Medical History
Conditions –
Medication –
Allergies –
Family Medical and Pain History
Current Living Environment
Who does the client life with? What is the circumstance of the home environment.
Life History
Childhood
Reared where?
Parents
Siblings
Discpline
Abuse
Education
Adult
Leaving Home
Marriage(s)
Domestic Abuse
Parental Discipline
Friends
Work History –
Where and for how long? What does the client do at this job?
Avocational Activities –
Hobbies?
Previous Psychological Testing and Treatment —
Expectation for Treatment Outcome
Diagnosis –
Summary and Recommendation
Summary of evaluative instruments
—
Recommendation —
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