Medical Status & Treatment History Current Medications (not listed above): Dosage & Date/Time Last Taken: Is the medication helpful or problematic: Known Medication Allergies: Currently Under Physician Care For: Physician’s Name: Conditions Treated In The Past: Provider/Dates: Medical Hospitalization History: Physical Disabilities: Current Communicable Diseases: A B C ☐HIV/AIDS ☐Hepatitis ☐Hepatitis ☐Hepatitis ☐TB(Tuberculosis) Lice Lice ☐MRSA ☐Influenza ☐Head ☐Scabies ☐Body ☐STIs ☐Other Currently Pregnant: Yes No ☐ ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Developmental Disability History of Special Education Ruling: Yes No ☐ ☐ If yes, describe: Documented IQ below 70: Yes No If yes, describe: ☐ ☐ Documented sub-average intellectual functioning before age If yes, describe: 18: Yes No ☐ ☐ Documented Adaptive Functioning Deficits: Yes No ☐ ☐ If yes, describe: Specific Observed Adaptive Functioning Deficits: Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other President: Oriented to Date: Time: Place: Mental State Exam *Cue for three words (provide words) Counting Response: Word Recall: Completed Written Command: Yes No If no, describe: ☐ ☐ What do you understand the reason for our meeting today to be? Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Psychiatric Symptoms Past Month Respondent( R ) Informant(I) Depressive Symptoms R I Anxiety Symptoms R I Somatic Symptoms R I ☐ ☐Depressed mood most of the day ☐ ☐ ☐ ☐ ☐ ☐ ☐Headaches ☐ Lack of Interest/Pleasure ☐ ☐ ☐ ☐ Restlessness Discomfort/Pain ☐ ☐ ☐ ☐Chest ☐ Appetite Change or Sig Weight ☐ ☐ ☐ ☐ Easily Fatigued ☐ ☐ ☐ ☐Faintness Change ☐ Insomnia (Difficulty Falling Asleep) ☐ ☐ ☐ ☐ Irritability Hot or Cold Flashes ☐ ☐ ☐ ☐ ☐ Feelings of Worthlessness ☐ ☐ ☐ ☐ Muscle Tension Aches/Pains ☐ ☐ ☐ ☐Stomach Difficulty Concentrating ☐ ☐ Heart Palpitations ☐ Fatigue or Loss of Energy ☐ ☐ ☐ ☐ ☐ ☐ ☐ Diminished Concentration ☐ ☐ ☐ ☐ Sleep Disturbance Dizziness or Vertigo ☐ ☐ ☐ ☐
Medical Status & Treatment History Current Medications (not listed above): Dosage & Date/Time Last Taken: Is the medication helpful or problematic: Known Medication Allergies: Currently Under Physician Care For: Physician’s Name: Conditions Treated In The Past: Provider/Dates: Medical Hospitalization History: Physical Disabilities: Current Communicable Diseases: ☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis) ☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other Currently Pregnant: ☐ Yes ☐ No Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Developmental Disability History of Special Education Ruling: ☐ Yes ☐ No If yes, describe: Documented IQ below 70: ☐ Yes ☐ No If yes, describe: Documented sub-average intellectual functioning before age 18: ☐ Yes ☐ No If yes, describe: Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe: Specific Observed Adaptive Functioning Deficits: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Oriented to Date: Time: Place: *Cue for three words (provide words) President: Mental State Exam Counting Response: Word Recall: Completed Written Command: ☐ Yes ☐ No If no, describe: What do you understand the reason for our meeting today to be? Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Psychiatric Symptoms Past Month Respondent( R ) Informant(I) Depressive Symptoms R I Anxiety Symptoms R I Somatic Symptoms R I ☐Depressed mood most of the day ☐ ☐ ☐ ☐ ☐ ☐Headaches ☐ ☐ ☐ Lack of Interest/Pleasure ☐ ☐ ☐ Restlessness ☐ ☐ ☐Chest Discomfort/Pain ☐ ☐ ☐ Appetite Change or Sig Weight Change ☐ ☐ ☐ Easily Fatigued ☐ ☐ ☐Faintness ☐ ☐ ☐ Insomnia (Difficulty Falling Asleep) ☐ ☐ ☐ Irritability ☐ ☐ ☐ Hot or Cold Flashes ☐ ☐ ☐ Feelings of Worthlessness ☐ ☐ ☐ Muscle Tension ☐ ☐ ☐Stomach Aches/Pains ☐ ☐ ☐ Fatigue or Loss of Energy ☐ ☐ ☐ Difficulty Concentrating ☐ ☐ ☐ Heart Palpitations ☐ ☐ ☐ Diminished Concentration ☐ ☐ ☐ Sleep Disturbance ☐ ☐ ☐ Dizziness or Vertigo ☐ ☐