Been Requested? Yes No □ □ Yes No □ □ Yes No □ □ Initial Observations Appearance: __________________________________ Appropriate Disheveled Unclean Other □ □ □ □ Speech: General _______________________________ Appropriate Slow Mechanical Rapid Other □ □ □ □ □ Observations Affect: __________________________________________ Appropriate Flat Labile Other □ □ □ □ N/A □ Delusions: Description: □ N/A □ Hallucinations: Description: □ Mood Appropriate Manic Depressed Labile Irritable Other _________________________ □ □ □ □ □ □ Orientation Person Place Time Situation Other ________________________________________ □ □ □ □ □ Indication Of Functional Limitation(s): (Check Major Life Areas Affected) Basic living skills (eating, bathing, dressing, etc.) Instrumental living skills (maintain a household, managing money, getting around the community, taking prescribed medications, etc.) Social functioning (ability to function within the family, vocational or educational function, other social contexts, etc.) SUMMARY / RECOMMENDATIONS Health: Home: Community: Purpose: Other: INITIAL DIAGNOSTIC IMPRESSION Codes: Description:
Been Requested? □ Yes □ No □ Yes □ No □ Yes □ No Initial Observations General Observations Appearance: □ Appropriate □ Disheveled □ Unclean □ Other __________________________________ Speech: □ Appropriate □ Slow □ Mechanical □ Rapid □ Other _______________________________ Affect: □ Appropriate □ Flat □ Labile □ Other __________________________________________ Delusions: □ N/A □ Description: Hallucinations: □ N/A □ Description: Mood □ Appropriate □ Manic □ Depressed □ Labile □ Irritable □ Other _________________________ Orientation □ Person □ Place □ Time □ Situation □ Other ________________________________________ Indication Of Functional Limitation(s): (Check Major Life Areas Affected) Basic living skills (eating, bathing, dressing, etc.) Instrumental living skills (maintain a household, managing money, getting around the community, taking prescribed medications, etc.) Social functioning (ability to function within the family, vocational or educational function, other social contexts, etc.) SUMMARY / RECOMMENDATIONS Health: Home: Community: Purpose: Other: INITIAL DIAGNOSTIC IMPRESSION Codes: Description: