Anxious Hopeful Tearful Appropriate Being Irritable Having Trouble Concentrating Bright Labile Withdrawn Distressed Expressing Loss of Pleasure Expressing Worthlessness Fatigued Being Sad Expressing Worry Flat Difficult or Unable to Assess Suicidal Ideation/Intentions: Frequency of occurrence: How long does it last: Intensity of suicidal thoughts: Reasons individual would rather die than live: Detailed Plan: Plan location: How lethal is the method: Access to lethal methods: If firearms, are they being removed from patient access: Steps taken to enact plan: Rehearsal behaviors: Obtained access: Details: Thought Process: Blocking Evasive Neologisms Circumstantial Flight of ideas Perseveration Clang Associations Incoherent, Logical Rational Coherent Loose Associations Tangential Egocentric Magical thinking Word Salad Test Results and Interpretation: (add as needed) Problem List: Lipids Diabetes mellitus Mood disorder Learning problems Heart disease Hyperlipidemia Personality disorder Cognitive impairment Obesity Seizure disorder Thought disorder Compliance difficulties Prior TIA / stroke Sedentary lifestyle Dementia Social isolation Hypertension Gastrointestinal problem Additional Comments: Diagnosis: Treatment Plan/Recommendations:
Anxious Appropriate Bright Distressed Fatigued Flat Hopeful Being Irritable Labile Expressing Loss of Pleasure Being Sad Tearful Having Trouble Concentrating Withdrawn Expressing Worthlessness Expressing Worry Difficult or Unable to Assess Suicidal Ideation/Intentions: Frequency of occurrence: How long does it last: Intensity of suicidal thoughts: Reasons individual would rather die than live: Detailed Plan: Plan location: How lethal is the method: Access to lethal methods: If firearms, are they being removed from patient access: Steps taken to enact plan: Rehearsal behaviors: Obtained access: Details: Thought Process: Blocking Circumstantial Clang Associations Coherent Egocentric Evasive Flight of ideas Incoherent, Logical Loose Associations Magical thinking Neologisms Perseveration Rational Tangential Word Salad Test Results and Interpretation: (add as needed) Problem List: Lipids Heart disease Obesity Prior TIA / stroke Hypertension Diabetes mellitus Hyperlipidemia Seizure disorder Sedentary lifestyle Gastrointestinal problem Mood disorder Personality disorder Thought disorder Dementia Learning problems Cognitive impairment Compliance difficulties Social isolation Additional Comments: Diagnosis: Treatment Plan/Recommendations:
idaho-intake-form.docx