Traumatic Stress Upsetting Memories Acute Repression Amnesia Nightmares Hyper Vigilance Chronic Detached Avoidance Other: No Problem Slight Moderate Serious Severe Extreme Brief justification, explanation, description: Interpersonal Relationships ` Adequate Social Skills Problems with Friend Age-Appropriate Group Activities Supportive Relations Difficulty Establishing Poor Social Skills Overly Shy Maintaining Friends No Supportive Relations Poor Boundaries No Problem Slight Moderate Serious Severe Extreme Brief justification, explanation, description: Medical / Physical Good Health Eating Disorder Poor Nutrition Central Nervous System Disorder Hypochondria Pregnant Stress Related Illness Chronic Illness Seizures – Need Medical/Dental Care Enuretic/Encopretic Acute Illness FAE/FAS Other: ALLERGIES CURRENT MEDICATIONS CURRENT PSYCH DIAGNOSIS CURRENT PSYCH MEDICATIONS No Problem Slight Moderate Serious Severe Extreme Brief justification, explanation, description: Substance Use No problem Cravings/Urges Alcohol Med Controlled Interferes Functioning Drugs Abstinent Abuse Over Counter Recovery Dependency IV Drugs Other: No Problem Slight Moderate Serious Severe Extreme
Traumatic Stress Acute Chronic Avoidance Upsetting Memories Nightmares Repression Hyper Vigilance Amnesia Detached Other: No Problem Slight Moderate Serious Severe Extreme Brief justification, explanation, description: Interpersonal Relationships Adequate Social Skills Supportive Relations Overly Shy No Supportive Relations ` Problems with Friend Difficulty Establishing Maintaining Friends Poor Boundaries Age-Appropriate Group Activities Poor Social Skills No Problem Slight Moderate Serious Severe Extreme Brief justification, explanation, description: Medical / Physical Good Health Central Nervous System Disorder Stress – Related Illness Need Medical/Dental Care FAE/FAS Eating Disorder Hypochondria Chronic Illness Enuretic/Encopretic Poor Nutrition Pregnant Seizures Acute Illness Other: ALLERGIES CURRENT MEDICATIONS CURRENT PSYCH DIAGNOSIS CURRENT PSYCH MEDICATIONS No Problem Slight Moderate Serious Severe Extreme Brief justification, explanation, description: Substance Use No problem Med Controlled Abstinent Recovery Cravings/Urges Interferes Functioning Abuse Dependency Alcohol Drugs Over Counter IV Drugs Other: No Problem Slight Moderate Serious Severe Extreme
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