TRAUMA / RISK (continued) Trauma Have You Ever Experienced Physical, Emotional, or Sexual Abuse or Neglect?  No  Yes  Unknown Abuse Comments: (Include current and past episodes). Physically, Emotionally, Sexually Abused Another Person?  No  Yes  Denies  Unknown Abuse Perpetrator Comments: Ever Tried to Hurt Yourself in the past? (If yes, complete self harm comments).  No  Yes  Denies  Unknown Thoughts of Doing Harm to Yourself Now? (If yes, complete self harm comments).  No  Yes  Denies  Unknown Self-Harm Comments: (Include client statements) (Complete Suicide Assessment) ALERTS / PLAN OF CARE Physician Alert:  No  Yes Physician Alert Type:    Audiologist Burn care Cardiology  Dental  Dermatology  Diabetic    Dietary Educational Infection control    Internal medicine Neurology Occupational therapy    Ophthalmologist / Optometrist Physical therapy    Speech therapy Wound care Other (specify) Physician Alert Comments: (Specify other and elaborate on physician alerts). 14
TRAUMA / RISK (continued) Trauma Have You Ever Experienced Physical, Emotional, or Sexual Abuse or Neglect?  No  Yes  Unknown Abuse Comments: (Include current and past episodes). Physically, Emotionally, Sexually Abused Another Person?  No  Yes  Denies  Unknown Abuse Perpetrator Comments: Ever Tried to Hurt Yourself in the past? (If yes, complete self harm comments).  No  Yes  Denies  Unknown Thoughts of Doing Harm to Yourself Now? (If yes, complete self harm comments).  No  Yes  Denies  Unknown Self-Harm Comments: (Include client statements) (Complete Suicide Assessment) ALERTS / PLAN OF CARE Physician Alert:  No  Yes Physician Alert Type:  Audiologist  Dental  Dietary  Internal medicine  Ophthalmologist / Optometrist  Speech therapy  Burn care  Dermatology  Educational  Neurology  Physical therapy  Wound care  Cardiology  Diabetic  Infection control  Occupational therapy   Other (specify) Physician Alert Comments: (Specify other and elaborate on physician alerts). 14
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