Demographics

+-------------------------------------+------------+-------------------+
| Client Name: **     **              | # D        |                   |
|                                     | ate:       |                   |
+-------------------------------------+------------+-------------------+
| # Current Address:                  | #          |                   |
|                                     | Phone #: ( |                   |
| Street                              |      )     |                   |
|                                     |    -       |                   |
| City/State                          |            |                   |
|                                     |            |                   |
| Zip Code                            |            |                   |
+-------------------------------------+------------+-------------------+
| # Date of Birth:                    | # Mari     |                   |
|                                     | tal/Relati |                   |
|                                     | onship Sta |                   |
|                                     | tus:       |                   |
+-------------------------------------+------------+-------------------+
| # Nation/Tribe/Ethnicity:           |            |                   |
+-------------------------------------+------------+-------------------+
| **Primary language of client:**     |            | **Secondary:**    |
|                                     |            |                   |
+-------------------------------------+------------+-------------------+
| **Referral Source:**                |            | **Phone:**        |
+-------------------------------------+------------+-------------------+
| **Emergency Contact:      **        |            | **Phone:      **  |
+-------------------------------------+------------+-------------------+

Critical Population (choose all that apply)

+-------------------+---+-----------------------+-----+----------------+
| ####              | # |                       | ### |                |
| ## Funding Source | # |                       | ### |                |
|                   | # |                       |  Le |                |
|                   | # |                       | gal |                |
|                   | # |                       |  In |                |
|                   | # |                       | vol |                |
|                   |   |                       | vem |                |
|                   | R |                       | ent |                |
|                   | e |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | d |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | i |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| Food Stamp        |   |                       |     |                |
| Recipient         | H |                       | P   |                |
|                   | o |                       | rot |                |
|                   | m |                       | ect |                |
|                   | e |                       | ive |                |
|                   | l |                       | Se  |                |
|                   | e |                       | rvi |                |
|                   | s |                       | ces |                |
|                   | s |                       | (AP |                |
|                   |   |                       | S/C |                |
|                   |   |                       | PS) |                |
+-------------------+---+-----------------------+-----+----------------+
| TANF Recipient    |   |                       |     |                |
|                   | S |                       | Co  |                |
|                   | h |                       | urt |                |
|                   | e |                       | O   |                |
|                   | l |                       | rde |                |
|                   | t |                       | red |                |
|                   | e |                       | Se  |                |
|                   | r |                       | rvi |                |
|                   | R |                       | ces |                |
|                   | e |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | d |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| SSI Recipient     |   |                       | On  |                |
|                   | L |                       | Pro |                |
|                   | o |                       | bat |                |
|                   | n |                       | ion |                |
|                   | g |                       |     |                |
|                   | T |                       |     |                |
|                   | e |                       |     |                |
|                   | r |                       |     |                |
|                   | m |                       |     |                |
|                   | C |                       |     |                |
|                   | a |                       |     |                |
|                   | r |                       |     |                |
|                   | e |                       |     |                |
|                   | E |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | g |                       |     |                |
|                   | i |                       |     |                |
|                   | b |                       |     |                |
|                   | i |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| SSDI Recipient    |   |                       | On  |                |
|                   | L |                       | Par |                |
|                   | o |                       | ole |                |
|                   | n |                       |     |                |
|                   | g |                       |     |                |
|                   | T |                       |     |                |
|                   | e |                       |     |                |
|                   | r |                       |     |                |
|                   | m |                       |     |                |
|                   | C |                       |     |                |
|                   | a |                       |     |                |
|                   | r |                       |     |                |
|                   | e |                       |     |                |
|                   | R |                       |     |                |
|                   | e |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | d |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| SSA (retirement)  |   |                       | On  |                |
| Recipient         |   |                       | Pr  |                |
|                   |   |                       | e-R |                |
|                   |   |                       | ele |                |
|                   |   |                       | ase |                |
+-------------------+---+-----------------------+-----+----------------+
| Other Retirement  | # |                       |     |                |
| Income            | # |                       | Man |                |
|                   | # |                       | dat |                |
|                   | # |                       | ory |                |
|                   | # |                       | M   |                |
|                   | # |                       | oni |                |
|                   |   |                       | tor |                |
|                   | D |                       | ing |                |
|                   | i |                       |     |                |
|                   | s |                       |     |                |
|                   | a |                       |     |                |
|                   | b |                       |     |                |
|                   | i |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| Medicaid          |   |                       |     |                |
| Recipient         | P |                       |     |                |
|                   | h |                       |     |                |
|                   | y |                       |     |                |
|                   | s |                       |     |                |
|                   | i |                       |     |                |
|                   | c |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | D |                       |     |                |
|                   | i |                       |     |                |
|                   | s |                       |     |                |
|                   | a |                       |     |                |
|                   | b |                       |     |                |
|                   | i |                       |     |                |
|                   | l |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| Medicare          |   |                       | ### |                |
| Recipient         | S |                       | ### |                |
|                   | e |                       |  Ot |                |
|                   | v |                       | her |                |
|                   | e |                       |     |                |
|                   | r |                       |     |                |
|                   | e |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | M |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | I |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| General           |   |                       |     |                |
| Assistance        | S |                       | Cur |                |
|                   | E |                       | ren |                |
|                   | D |                       | tly |                |
|                   |   |                       | pr  |                |
|                   |   |                       | egn |                |
|                   |   |                       | ant |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
|                   | D |                       | Wo  |                |
|                   | e |                       | man |                |
|                   | v |                       | w/d |                |
|                   | e |                       | epe |                |
|                   | l |                       | nde |                |
|                   | o |                       | nts |                |
|                   | p |                       |     |                |
|                   | m |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | D |                       |     |                |
|                   | i |                       |     |                |
|                   | s |                       |     |                |
|                   | a |                       |     |                |
|                   | b |                       |     |                |
|                   | l |                       |     |                |
|                   | e |                       |     |                |
|                   | d |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
|                   | C |                       |     |                |
|                   | h |                       |     |                |
|                   | r |                       |     |                |
|                   | o |                       |     |                |
|                   | n |                       |     |                |
|                   | i |                       |     |                |
|                   | c |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | M |                       |     |                |
|                   | e |                       |     |                |
|                   | n |                       |     |                |
|                   | t |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
|                   | y |                       |     |                |
|                   | I |                       |     |                |
|                   | l |                       |     |                |
|                   | l |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
|                   | R |                       |     |                |
|                   | e |                       |     |                |
|                   | g |                       |     |                |
|                   | i |                       |     |                |
|                   | o |                       |     |                |
|                   | n |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | B |                       |     |                |
|                   | e |                       |     |                |
|                   | h |                       |     |                |
|                   | a |                       |     |                |
|                   | v |                       |     |                |
|                   | i |                       |     |                |
|                   | o |                       |     |                |
|                   | r |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | H |                       |     |                |
|                   | e |                       |     |                |
|                   | a |                       |     |                |
|                   | l |                       |     |                |
|                   | t |                       |     |                |
|                   | h |                       |     |                |
|                   | A |                       |     |                |
|                   | u |                       |     |                |
|                   | t |                       |     |                |
|                   | h |                       |     |                |
|                   | o |                       |     |                |
|                   | r |                       |     |                |
|                   | i |                       |     |                |
|                   | t |                       |     |                |
|                   | y |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| ###### Co         |   |                       |     |                |
| ntact Information |   |                       |     |                |
|                   |   |                       |     |                |
| **(Secure         |   |                       |     |                |
| consents for      |   |                       |     |                |
| agency contacts,  |   |                       |     |                |
| when possible)**  |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
| # N               |   | **Agency**            |     | **Phone        |
| ame of Caseworker |   |                       |     | number**       |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+
|                   |   |                       |     |                |
+-------------------+---+-----------------------+-----+----------------+

Family Relationships

<table>
<colgroup>
<col style="width: 33%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 9%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 12%" />
<col style="width: 16%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><h1 id="does-the-client-have-any-children">Does the
client have any children?</h1></td>
</tr>
<tr class="even">
<td><h1 id="name">Name</h1></td>
<td><h1 id="age">Age</h1></td>
<td colspan="2"><h1 id="date-of-birth-1">Date of Birth</h1></td>
<td colspan="2"><h1 id="sex">Sex</h1></td>
<td colspan="2"><h1 id="custody">Custody?</h1>
<h1 id="yn">Y/N</h1></td>
<td colspan="2"><h1 id="lives-with">Lives with?</h1></td>
<td><h1 id="additional-information">Additional Information</h1></td>
</tr>
<tr class="odd">
<td><h1 id="section">     </h1></td>
<td><h1 id="section-1">     </h1></td>
<td colspan="2"><h1 id="section-2">     </h1></td>
<td colspan="2"><h1 id="section-3">     </h1></td>
<td colspan="2"><h1 id="section-4">     </h1></td>
<td colspan="2"><h1 id="section-5">     </h1></td>
<td><h1 id="section-6">     </h1></td>
</tr>
<tr class="even">
<td><h1 id="section-7">     </h1></td>
<td><h1 id="section-8">     </h1></td>
<td colspan="2"><h1 id="section-9">     </h1></td>
<td colspan="2"><h1 id="section-10">     </h1></td>
<td colspan="2"><h1 id="section-11">     </h1></td>
<td colspan="2"><h1 id="section-12">     </h1></td>
<td><h1 id="section-13">     </h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-14">     </h1></td>
<td><h1 id="section-15">     </h1></td>
<td colspan="2"><h1 id="section-16">     </h1></td>
<td colspan="2"><h1 id="section-17">     </h1></td>
<td colspan="2"><h1 id="section-18">     </h1></td>
<td colspan="2"><h1 id="section-19">     </h1></td>
<td><h1 id="section-20">     </h1></td>
</tr>
<tr class="even">
<td><h1 id="section-21">     </h1></td>
<td><h1 id="section-22">     </h1></td>
<td colspan="2"><h1 id="section-23">     </h1></td>
<td colspan="2"><h1 id="section-24">     </h1></td>
<td colspan="2"><h1 id="section-25">     </h1></td>
<td colspan="2"><h1 id="section-26">     </h1></td>
<td><h1 id="section-27">     </h1></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Who else lives with the client? (Include
spouses, partners, siblings, parents, other relatives,
friends)</strong></td>
</tr>
<tr class="even">
<td><strong>Name</strong></td>
<td colspan="2"><strong>Age</strong></td>
<td colspan="2"><h1 id="sex-1">Sex</h1></td>
<td colspan="4"><h1 id="relationship">Relationship</h1></td>
<td colspan="2"><h1 id="additional-information-1">Additional
Information</h1></td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="7"><strong>Primary language of household/family:</strong>
     </td>
<td colspan="4"><strong>Secondary:</strong>      </td>
</tr>
<tr class="even">
<td colspan="11"><strong>Client’s/Family’s Presentation of the Problem:
     </strong></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Client’s/Family’s Expected Outcome:
     </strong></td>
</tr>
</tbody>
</table>

  ---------------------------------------------------- --------- --------
  Physical                                             Yes       No

  Client states that he/she has an exercise program.                  
  *Optional - Physical Fitness*                                  

  Client reports appropriate interventions taken when                 
  experiencing illness or injury.                                

  Client engages in preventive medicine activities                    
  such as breast or testes self-examination.                     

  Client receives an adequate amount of sleep. *If No,                
  explain below in Comments section*                             

  Client avoids the use of tobacco products or                        
  exposure to second-hand smoke. *If NO, complete                
  Behavioral Assessment*                                         

  Client consumes no more than two alcoholic drinks                   
  per day. *If NO, complete Behavioral Assessment*               

  Allergies (Medication and Other):                              

  Additional Information:                                        
  ---------------------------------------------------- --------- --------

# Nutrition 

+-----------------------------------------+-----------------------------+
| ######  {#section-28}                   |                             |
|                                         |                             |
| ###### Nutritional Status: Current Weig |                             |
| ht       Current Height       BMI       |                             |
+-----------------------------------------+-----------------------------+
| ###### Appetite:                        |                             |
|  Good  Fair  Poor, please explain below |                             |
+-----------------------------------------+-----------------------------+
| ######                                  | ######                      |
| Recently gained/lost significant weight |   Binges/overeats to excess |
+-----------------------------------------+-----------------------------+
| ######  Restricts food/Vom              | ##                          |
| its/over-exercises to avoid weight gain | ####  Special dietary needs |
+-----------------------------------------+-----------------------------+
| ######  Hiding/hording food             | ######  Food allergies      |
+-----------------------------------------+-----------------------------+
| ###### Comments                         |                             |
+-----------------------------------------+-----------------------------+

# Pain Questionnaire

+-----------------------------------------------------------------------+
| ######  {#section-29}                                                 |
|                                                                       |
| ###### Pain Management: Is the client in pain now?  Yes  No           |
|                                                                       |
| If yes, ask client to rate the pain on a scale of 1-10 (with 10 being |
| the severest) and                                                     |
|                                                                       |
| enter score here                                                      |
|                                                                       |
| Is the client receiving care for the pain? Yes No                     |
|                                                                       |
| If no, would the client like a referral for pain management? Yes No   |
+-----------------------------------------------------------------------+

Child/Adolescent Growth & Development

+----------------+-----+-----------+-----------+-----+-----------------+
| ###            |     |           |           |     |                 |
| ### During pre |     |           |           |     |                 |
| gnancy, did th |     |           |           |     |                 |
| e biological m |     |           |           |     |                 |
| other have any |     |           |           |     |                 |
|  of the follow |     |           |           |     |                 |
| ing (select al |     |           |           |     |                 |
| l that apply)? |     |           |           |     |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| ######         |     | #####     |           | ##  |                 |
|  Amniocentesis |     | #  Anemia |           | ### |                 |
|                |     |           |           | #   |                 |
|                |     |           |           | Dia |                 |
|                |     |           |           | bet |                 |
|                |     |           |           | es  |                 |
|                |     |           |           | Mel |                 |
|                |     |           |           | lli |                 |
|                |     |           |           | tus |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| ######  Emot   |     | ##        |           | #   |                 |
| ional Problems |     | ####  Exc |           | ### |                 |
|                |     | essive we |           | ##  |                 |
|                |     | ight gain |           |  Ge |                 |
|                |     |           |           | rma |                 |
|                |     |           |           | n M |                 |
|                |     |           |           | eas |                 |
|                |     |           |           | les |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| ######  High   |     | ######  H |           | ##  |                 |
| blood pressure |     | igh fever |           | ### |                 |
|                |     |           |           | #   |                 |
|                |     |           |           | Kid |                 |
|                |     |           |           | ney |                 |
|                |     |           |           |  pr |                 |
|                |     |           |           | obl |                 |
|                |     |           |           | ems |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| ######  No     |     | #####     |           | ##  |                 |
|  prenatal care |     | #  Placen |           | ### |                 |
|                |     | ta Previa |           | #   |                 |
|                |     |           |           | Pre |                 |
|                |     |           |           | mat |                 |
|                |     |           |           | ure |                 |
|                |     |           |           |  la |                 |
|                |     |           |           | bor |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| ######  Va     |     | ######    |           | ##  |                 |
| ginal bleeding |     |  Vaginal  |           | ### |                 |
|                |     | infection |           | #   |                 |
|                |     |           |           | Oth |                 |
|                |     |           |           | er  |                 |
|                |     |           |           | inf |                 |
|                |     |           |           | ect |                 |
|                |     |           |           | ion |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| #              |     | ##        |           |     |                 |
| #####  Unknown |     | ####  Oth |           |     |                 |
|                |     | er:       |           |     |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| #####          |     |           |           |     |                 |
| # During pregn |     |           |           |     |                 |
| ancy, did the  |     |           |           |     |                 |
| mother use any |     |           |           |     |                 |
|  of the follow |     |           |           |     |                 |
| ing (select al |     |           |           |     |                 |
| l that apply)? |     |           |           |     |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| #              | ### |           | ##        |     | ######  Unknown |
| #####  Tobacco | ### |           | ####  Str |     |                 |
|                |   A |           | eet Drugs |     |                 |
|                | lco |           |           |     |                 |
|                | hol |           |           |     |                 |
+----------------+-----+-----------+-----------+-----+-----------------+
| ###### Comment |     |           |           |     |                 |
| s (frequency a |     |           |           |     |                 |
| nd intensity o |     |           |           |     |                 |
| f use, partici |     |           |           |     |                 |
| pation in trea |     |           |           |     |                 |
| tment, birth d |     |           |           |     |                 |
| efects or malf |     |           |           |     |                 |
| ormations due  |     |           |           |     |                 |
| to drug/alcoho |     |           |           |     |                 |
| l use among si |     |           |           |     |                 |
| blings):       |     |           |           |     |                 |
+----------------+-----+-----------+-----------+-----+-----------------+

+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Any     |     |           |            |   |   |                 |
|  problems with |     |           |            |   |   |                 |
|  labor &/or de |     |           |            |   |   |                 |
| livery?        |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| ######         |     |           |            |   |   |                 |
|  {#section-30} |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| ######         |     |           |            |   |   |                 |
|  {#section-31} |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| ###### Apgar   |     |           |            |   |   |                 |
|  Scores?       |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #              |     |           |            |   |   |                 |
| ##### Did the  |     |           |            |   |   |                 |
| baby have any  |     |           |            |   |   |                 |
| of the followi |     |           |            |   |   |                 |
| ng after deliv |     |           |            |   |   |                 |
| ery (select al |     |           |            |   |   |                 |
| l that apply)? |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######  Anemia | #   |           | #          |   | # |                 |
|                | ### |           | #####  Bir |   | # |                 |
|                | ##  |           | th defects |   | # |                 |
|                |  Ap |           |            |   | # |                 |
|                | nea |           |            |   | # |                 |
|                |     |           |            |   | # |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | B |                 |
|                |     |           |            |   | l |                 |
|                |     |           |            |   | o |                 |
|                |     |           |            |   | o |                 |
|                |     |           |            |   | d |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | a |                 |
|                |     |           |            |   | n |                 |
|                |     |           |            |   | s |                 |
|                |     |           |            |   | f |                 |
|                |     |           |            |   | u |                 |
|                |     |           |            |   | s |                 |
|                |     |           |            |   | i |                 |
|                |     |           |            |   | o |                 |
|                |     |           |            |   | n |                 |
|                |     |           |            |   | s |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #####          | ### |           | ######  Ey |   | # |                 |
| #  Bradycardia | ### |           | e problems |   | # |                 |
|                |   C |           |            |   | # |                 |
|                | ord |           |            |   | # |                 |
|                |  ar |           |            |   | # |                 |
|                | oun |           |            |   | # |                 |
|                | d n |           |            |   |   |                 |
|                | eck |           |            |   |   |                 |
|                |     |           |            |   | F |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | v |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | / |                 |
|                |     |           |            |   | l |                 |
|                |     |           |            |   | o |                 |
|                |     |           |            |   | w |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | m |                 |
|                |     |           |            |   | p |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | a |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | u |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | e |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######  Hernia | ### |           | ######     |   | # |                 |
|                | ### |           |  Infection |   | # |                 |
|                |   H |           |            |   | # |                 |
|                | ydr |           |            |   | # |                 |
|                | oce |           |            |   | # |                 |
|                | pha |           |            |   | # |                 |
|                | lus |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | I |                 |
|                |     |           |            |   | n |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | n |                 |
|                |     |           |            |   | s |                 |
|                |     |           |            |   | i |                 |
|                |     |           |            |   | v |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | C |                 |
|                |     |           |            |   | a |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | e |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######  Intr   | #   |           | ###        |   | # |                 |
| acranial bleed | ### |           | ###  Physi |   | # |                 |
|                | ##  |           | cal injury |   | # |                 |
|                |  Ji |           |            |   | # |                 |
|                | tte |           |            |   | # |                 |
|                | rin |           |            |   | # |                 |
|                | ess |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | S |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | i |                 |
|                |     |           |            |   | z |                 |
|                |     |           |            |   | u |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | s |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ####           | #   |           | ###        |   | # |                 |
| ##  Surfactant | ### |           | ###  Troub |   | # |                 |
|                | ##  |           | le sucking |   | # |                 |
|                |  Tr |           |            |   | # |                 |
|                | oub |           |            |   | # |                 |
|                | le  |           |            |   | # |                 |
|                | bre |           |            |   |   |                 |
|                | ath |           |            |   |   |                 |
|                | ing |           |            |   | 1 |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | o |                 |
|                |     |           |            |   | f |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | m |                 |
|                |     |           |            |   | u |                 |
|                |     |           |            |   | l |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | i |                 |
|                |     |           |            |   | p |                 |
|                |     |           |            |   | l |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | s |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | ( |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | w |                 |
|                |     |           |            |   | i |                 |
|                |     |           |            |   | n |                 |
|                |     |           |            |   | , |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | c |                 |
|                |     |           |            |   | ) |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         | ### |           | ###        |   | # |                 |
|  Use of Oxygen | ### |           | ###  Yello |   | # |                 |
|                |   V |           | w Jaundice |   | # |                 |
|                | ent |           |            |   | # |                 |
|                | ila |           |            |   | # |                 |
|                | tor |           |            |   | # |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   | O |                 |
|                |     |           |            |   | t |                 |
|                |     |           |            |   | h |                 |
|                |     |           |            |   | e |                 |
|                |     |           |            |   | r |                 |
|                |     |           |            |   | : |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     |           |            |   |   |                 |
|  {#section-32} |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| ###### Devel   |     |           |            |   |   |                 |
| opmental Miles |     |           |            |   |   |                 |
| tones -- pleas |     |           |            |   |   |                 |
| e select any t |     |           |            |   |   |                 |
| hat the client |     |           |            |   |   |                 |
|  did late or i |     |           |            |   |   |                 |
| s still having |     |           |            |   |   |                 |
|  trouble with: |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #####          |     | ##        |            | # |   |                 |
| #  Rolling Ove |     | ####  Sit |            | # |   |                 |
| r (2-6 months) |     | ting (6-1 |            | # |   |                 |
|                |     | 2 months) |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | S |   |                 |
|                |     |           |            | t |   |                 |
|                |     |           |            | a |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | d |   |                 |
|                |     |           |            | i |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | g |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | ( |   |                 |
|                |     |           |            | 8 |   |                 |
|                |     |           |            | - |   |                 |
|                |     |           |            | 1 |   |                 |
|                |     |           |            | 6 |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | m |   |                 |
|                |     |           |            | o |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | t |   |                 |
|                |     |           |            | h |   |                 |
|                |     |           |            | s |   |                 |
|                |     |           |            | ) |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #              |     | #         |            | # |   |                 |
| #####  Walking |     | #####  En |            | # |   |                 |
|  (8-16 months) |     | gaging pe |            | # |   |                 |
|                |     | ers (24-3 |            | # |   |                 |
|                |     | 6 months) |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | T |   |                 |
|                |     |           |            | o |   |                 |
|                |     |           |            | i |   |                 |
|                |     |           |            | l |   |                 |
|                |     |           |            | e |   |                 |
|                |     |           |            | t |   |                 |
|                |     |           |            | i |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | g |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | ( |   |                 |
|                |     |           |            | 2 |   |                 |
|                |     |           |            | 4 |   |                 |
|                |     |           |            | - |   |                 |
|                |     |           |            | 3 |   |                 |
|                |     |           |            | 6 |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | m |   |                 |
|                |     |           |            | o |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | t |   |                 |
|                |     |           |            | h |   |                 |
|                |     |           |            | s |   |                 |
|                |     |           |            | ) |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     | ##        |            | # |   |                 |
| Dressing self  |     | ####  Fee |            | # |   |                 |
| (24-36 months) |     | ding Self |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | S |   |                 |
|                |     |           |            | l |   |                 |
|                |     |           |            | e |   |                 |
|                |     |           |            | e |   |                 |
|                |     |           |            | p |   |                 |
|                |     |           |            | i |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | g |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | a |   |                 |
|                |     |           |            | l |   |                 |
|                |     |           |            | o |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | e |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #              |     | ##        |            | # |   |                 |
| #####  Tolerat |     | ####  Pla |            | # |   |                 |
| ing separation |     | ying coop |            | # |   |                 |
|                |     | eratively |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            | # |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
|                |     |           |            | S |   |                 |
|                |     |           |            | p |   |                 |
|                |     |           |            | e |   |                 |
|                |     |           |            | a |   |                 |
|                |     |           |            | k |   |                 |
|                |     |           |            | i |   |                 |
|                |     |           |            | n |   |                 |
|                |     |           |            | g |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     |           |            |   |   |                 |
|  {#section-33} |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| ###            |     |           |            |   |   |                 |
| ### Are immuni |     |           |            |   |   |                 |
| zations up to  |     |           |            |   |   |                 |
| date?  Yes  No |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     |           |            |   |   |                 |
|  {#section-34} |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| #              |     |           |            |   |   |                 |
| ##### Has the  |     |           |            |   |   |                 |
| client had any |     |           |            |   |   |                 |
|  of the follow |     |           |            |   |   |                 |
| ing (select al |     |           |            |   |   |                 |
| l that apply)? |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Bl      |     |           |            |   |   |                 |
| ood Disorders: |     |           |            |   |   |                 |
|   Anemia  Blee |     |           |            |   |   |                 |
| ding  Bruising |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Brain   |     |           |            |   |   |                 |
|  Disorders:  C |     |           |            |   |   |                 |
| onfusion  Head |     |           |            |   |   |                 |
| aches  Coordin |     |           |            |   |   |                 |
| ation Problems |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| Muscle         |     |           |            |   |   |                 |
| Weakness       |     |           |            |   |   |                 |
| Staring        |     |           |            |   |   |                 |
| Tremors        |     |           |            |   |   |                 |
|                |     |           |            |   |   |                 |
| Tics           |     |           |            |   |   |                 |
| (motor/vocal)  |     |           |            |   |   |                 |
| Head Injuries  |     |           |            |   |   |                 |
| Seizures       |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     |           |            |   |   |                 |
|  GI Problems:  |     |           |            |   |   |                 |
|  Constipation  |     |           |            |   |   |                 |
|  Diarrhea  Soi |     |           |            |   |   |                 |
| ling  Vomiting |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     |           |            |   |   |                 |
|  Heart/Lung Pr |     |           |            |   |   |                 |
| oblems:  Asthm |     |           |            |   |   |                 |
| a  Chest Pain  |     |           |            |   |   |                 |
|  Murmur  Surge |     |           |            |   |   |                 |
| ry  Congenital |     |           |            |   |   |                 |
|  Heart Disease |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #              |     |           |            |   |   |                 |
| ##### Hormone  |     |           |            |   |   |                 |
| Problems:  Obe |     |           |            |   |   |                 |
| sity  Thyroid  |     |           |            |   |   |                 |
|  Early Puberty |     |           |            |   |   |                 |
|   Late Puberty |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| #####          | #   |           | #####      |   |   | ######  S       |
| # Infections:  | ### |           | #  Measles |   |   | inus infections |
|                | ##  |           |            |   |   |                 |
|                |  Ch |           |            |   |   |                 |
|                | ick |           |            |   |   |                 |
|                | en  |           |            |   |   |                 |
|                | Pox |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         | ### |           | ##         |   |   | #####           |
| Ear infections | ### |           | ####  Whoo |   |   | #  Encephalitis |
|                |   M |           | ping Cough |   |   |                 |
|                | eni |           |            |   |   |                 |
|                | ngi |           |            |   |   |                 |
|                | tis |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######  Mumps  | #   |           | ######     |   |   | #####           |
|                | ### |           |  Pneumonia |   |   | #  Other:       |
|                | ##  |           |            |   |   |                 |
|                |  Hi |           |            |   |   |                 |
|                | gh  |           |            |   |   |                 |
|                | fev |           |            |   |   |                 |
|                | ers |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Injur   |     |           |            |   |   |                 |
| ies:  Broken B |     |           |            |   |   |                 |
| ones  Stitches |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Ki      |     |           |            |   |   |                 |
| dney Problems: |     |           |            |   |   |                 |
|   Bed wetting  |     |           |            |   |   |                 |
|  Daytime wetti |     |           |            |   |   |                 |
| ng  Infections |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Mu      |     |           |            |   |   |                 |
| scle/Bone Prob |     |           |            |   |   |                 |
| lems:  Scolios |     |           |            |   |   |                 |
| is  Spasticity |     |           |            |   |   |                 |
|   Other:       |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ######         |     |           |            |   |   |                 |
|  Poisoning:  C |     |           |            |   |   |                 |
| hemicals  Lead |     |           |            |   |   |                 |
|   Other:       |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### S       |     |           |            |   |   |                 |
| ensory Problem |     |           |            |   |   |                 |
| s:  Hearing  T |     |           |            |   |   |                 |
| actile  Vision |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### Se      |     |           |            |   |   |                 |
| xual Problems: |     |           |            |   |   |                 |
|   Birth Contro |     |           |            |   |   |                 |
| l  Masturbatio |     |           |            |   |   |                 |
| n  Promiscuity |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ####           |     |           |            |   |   |                 |
| ## Skin Disord |     |           |            |   |   |                 |
| ers:  Acne  Bi |     |           |            |   |   |                 |
| rth Marks  Ecz |     |           |            |   |   |                 |
| ema  Hair Loss |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+
| ###### C       |     |           |            |   |   |                 |
| omments:       |     |           |            |   |   |                 |
+----------------+-----+-----------+------------+---+---+-----------------+

Family History

+------------------------+------+-----+------+-----+------+----------+
| #####                  |      |     |      |     |      |          |
| # Family History of (s |      |     |      |     |      |          |
| elect all that apply): |      |     |      |     |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  {#section-35}  | #    | #   | ###  | ##  | #    | ###      |
|                        | #### | ### | ###  | ### | #### | ### Gran |
|                        | # Mo | ##  | Sibl | # A | # Un | dparents |
|                        | ther | Fat | ings | unt | cle  |          |
|                        |      | her |      |     |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ###### A               | ##   | ##  | ##   | ##  | ##   | ##       |
| lcohol/Substance Abuse | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-41} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -36} | cti | -38} | cti | -40} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 37} |      | 39} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ###### Histor          | ##   | ##  | ##   | ##  | ##   | ##       |
| y of Completed Suicide | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-47} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -42} | cti | -44} | cti | -46} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 43} |      | 45} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######                 | #    | ### | #    | ### | #    | #####    |
|  History of Mental Ill | #### | ### | #### | ### | #### | #  {#sec |
| ness/Problems such as: | #  { |   { | #  { |   { | #  { | tion-53} |
|                        | #sec | #se | #sec | #se | #sec |          |
|                        | tion | cti | tion | cti | tion |          |
|                        | -48} | on- | -50} | on- | -52} |          |
|                        |      | 49} |      | 51} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Depression     | ##   | ##  | ##   | ##  | ##   | ##       |
|                        | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-59} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -54} | cti | -56} | cti | -58} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 55} |      | 57} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Schizophrenia  | ##   | ##  | ##   | ##  | ##   | ##       |
|                        | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-65} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -60} | cti | -62} | cti | -64} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 61} |      | 63} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ##                     | ##   | ##  | ##   | ##  | ##   | ##       |
| ####  Bipolar Disorder | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-71} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -66} | cti | -68} | cti | -70} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 67} |      | 69} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Alzheimer's    | ##   | ##  | ##   | ##  | ##   | ##       |
|                        | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-77} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -72} | cti | -74} | cti | -76} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 73} |      | 75} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Anxiety        | ##   | ##  | ##   | ##  | ##   | ##       |
|                        | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-83} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -78} | cti | -80} | cti | -82} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 79} |      | 81} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Attention      | ##   | ##  | ##   | ##  | ##   | ##       |
|  Deficit/Hyperactivity | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-89} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -84} | cti | -86} | cti | -88} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 85} |      | 87} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ####                   | ##   | ##  | ##   | ##  | ##   | ##       |
| ##  Learning Disorders | #### | ### | #### | ### | #### | ####     |
|                        |      | #   |      | #   |      |    {#sec |
|                        |    { |     |    { |     |    { | tion-95} |
|                        | #sec |   { | #sec |   { | #sec |          |
|                        | tion | #se | tion | #se | tion |          |
|                        | -90} | cti | -92} | cti | -94} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 91} |      | 93} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Sc             | ##   | ##  | ##   | ##  | ###  | ###      |
| hool Behavior Problems | #### | ### | #### | ### | ###  | ###      |
|                        |      | #   |      | #   |      |   {#sect |
|                        |    { |     |    { |     |   {# | ion-101} |
|                        | #sec |   { | #sec |   { | sect |          |
|                        | tion | #se | tion | #se | ion- |          |
|                        | -96} | cti | -98} | cti | 100} |          |
|                        |      | on- |      | on- |      |          |
|                        |      | 97} |      | 99} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Incarceration  | ###  | ### | ###  | ### | ###  | ###      |
|                        | ###  | ### | ###  | ### | ###  | ###      |
|                        |      |     |      |     |      |   {#sect |
|                        |   {# |     |   {# |     |   {# | ion-107} |
|                        | sect |  {# | sect |  {# | sect |          |
|                        | ion- | sec | ion- | sec | ion- |          |
|                        | 102} | tio | 104} | tio | 106} |          |
|                        |      | n-1 |      | n-1 |      |          |
|                        |      | 03} |      | 05} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ######  Other          | ###  | ### | ###  | ### | ###  | ###      |
|                        | ###  | ### | ###  | ### | ###  | ###      |
|                        |      |     |      |     |      |   {#sect |
|                        |   {# |     |   {# |     |   {# | ion-113} |
|                        | sect |  {# | sect |  {# | sect |          |
|                        | ion- | sec | ion- | sec | ion- |          |
|                        | 108} | tio | 110} | tio | 112} |          |
|                        |      | n-1 |      | n-1 |      |          |
|                        |      | 09} |      | 11} |      |          |
+------------------------+------+-----+------+-----+------+----------+
| ###### Comments:       |      |     |      |     |      |          |
+------------------------+------+-----+------+-----+------+----------+

+-------------------------------------------------------+-------+------+
| # Social                                              | # Yes | # No |
+-------------------------------------------------------+-------+------+
| # Client re                                           | #     | #    |
| ports satisfaction with his/her family relationships. |       |      |
|                                                       |  {#se |   {# |
|                                                       | ction | sect |
|                                                       | -114} | ion- |
|                                                       |       | 115} |
+-------------------------------------------------------+-------+------+
| # Client reports satisfact                            | #     | #    |
| ion with his/her social relationships and activities. |       |      |
|                                                       |  {#se |   {# |
|                                                       | ction | sect |
|                                                       | -116} | ion- |
|                                                       |       | 117} |
+-------------------------------------------------------+-------+------+
| # Client reports satisfaction with the                | #     | #    |
| entertainment/recreational activities he/she selects. |       |      |
|                                                       |  {#se |   {# |
|                                                       | ction | sect |
|                                                       | -118} | ion- |
|                                                       |       | 119} |
+-------------------------------------------------------+-------+------+
| # Client expresses an                                 | #     | #    |
|  interest in his community and the world, in general. |       |      |
|                                                       |  {#se |   {# |
|                                                       | ction | sect |
|                                                       | -120} | ion- |
|                                                       |       | 121} |
+-------------------------------------------------------+-------+------+
| # Client has a history of or current legal i          | #     | #    |
| nvolvement. *If Yes, complete Legal Status Screening* |       |      |
|                                                       |  {#se |   {# |
|                                                       | ction | sect |
|                                                       | -122} | ion- |
|                                                       |       | 123} |
+-------------------------------------------------------+-------+------+
| # Comments:                                           |       |      |
+-------------------------------------------------------+-------+------+

#  {#section-124}

# Legal History

+-----------------------+-----------------------+-----------------------+
| # Past or curre       |                       |                       |
| nt legal problems (se |                       |                       |
| lect all that apply)? |                       |                       |
+-----------------------+-----------------------+-----------------------+
| None                  | Gangs                 | DUI/DWI               |
+-----------------------+-----------------------+-----------------------+
| Arrests               | Conviction            | Detention             |
+-----------------------+-----------------------+-----------------------+
| Jail                  | Probation             | Other                 |
+-----------------------+-----------------------+-----------------------+
| **If yes to any of    |                       |                       |
| the above, please     |                       |                       |
| explain:**            |                       |                       |
+-----------------------+-----------------------+-----------------------+
| **Any court-ordered   |                       |                       |
| treatment?** Yes      |                       |                       |
| (explain below) No    |                       |                       |
+-----------------------+-----------------------+-----------------------+
| ###### Ordered by     | **Offense**           | **Length of Time**    |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       |                       |                       |
+-----------------------+-----------------------+-----------------------+

# Functional Assessment 

+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Functio  |   |   |           |   |        |     |     |          |
| nal Assessment: |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
| Is client able  |   |   |           |   |        |     |     |          |
| to care for     |   |   |           |   |        |     |     |          |
| him/herself?    |   |   |           |   |        |     |     |          |
| Yes No If No,   |   |   |           |   |        |     |     |          |
| please explain: |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ###### Li       |   |   |           |   |        |     |     |          |
| ving Situation: |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######  H       |   | # |           |   | ###    |     |     | ######   |
| ousing Adequate |   | # |           |   | ###  H |     |     | Homeless |
|                 |   | # |           |   | ousing |     |     |          |
|                 |   | # |           |   |  Overc |     |     |          |
|                 |   | # |           |   | rowded |     |     |          |
|                 |   | # |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   | H |           |   |        |     |     |          |
|                 |   | o |           |   |        |     |     |          |
|                 |   | u |           |   |        |     |     |          |
|                 |   | s |           |   |        |     |     |          |
|                 |   | i |           |   |        |     |     |          |
|                 |   | n |           |   |        |     |     |          |
|                 |   | g |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   | D |           |   |        |     |     |          |
|                 |   | a |           |   |        |     |     |          |
|                 |   | n |           |   |        |     |     |          |
|                 |   | g |           |   |        |     |     |          |
|                 |   | e |           |   |        |     |     |          |
|                 |   | r |           |   |        |     |     |          |
|                 |   | o |           |   |        |     |     |          |
|                 |   | u |           |   |        |     |     |          |
|                 |   | s |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######  Depend  |   | # |           |   | ####   |     |     |          |
| ent Upon Others |   | # |           |   | ##  Wa |     |     |          |
|                 |   | # |           |   | rd of  |     |     |          |
|                 |   | # |           |   | State/ |     |     |          |
|                 |   | # |           |   | Tribal |     |     |          |
|                 |   | # |           |   |  Court |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   | I |           |   |        |     |     |          |
|                 |   | n |           |   |        |     |     |          |
|                 |   | c |           |   |        |     |     |          |
|                 |   | a |           |   |        |     |     |          |
|                 |   | r |           |   |        |     |     |          |
|                 |   | c |           |   |        |     |     |          |
|                 |   | e |           |   |        |     |     |          |
|                 |   | r |           |   |        |     |     |          |
|                 |   | a |           |   |        |     |     |          |
|                 |   | t |           |   |        |     |     |          |
|                 |   | e |           |   |        |     |     |          |
|                 |   | d |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ####            |   |   |           |   |        |     |     |          |
| ## Additional I |   |   |           |   |        |     |     |          |
| nformation:     |   |   |           |   |        |     |     |          |
|    {#additional |   |   |           |   |        |     |     |          |
| -information-2} |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######          |   |   |           |   |        |     |     |          |
|  {#section-125} |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
| ###### Uses or  |   |   |           |   |        |     |     |          |
| Needs assistive |   |   |           |   |        |     |     |          |
|  or adaptive de |   |   |           |   |        |     |     |          |
| vices (select a |   |   |           |   |        |     |     |          |
| ll that apply): |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######  None    | # |   |           | # |        |     | ### |          |
|                 | # |   |           | # |        |     | ### |          |
|                 | # |   |           | # |        |     |   B |          |
|                 | # |   |           | # |        |     | rai |          |
|                 | # |   |           | # |        |     | lle |          |
|                 | # |   |           | # |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 | G |   |           | W |        |     |     |          |
|                 | l |   |           | a |        |     |     |          |
|                 | a |   |           | l |        |     |     |          |
|                 | s |   |           | k |        |     |     |          |
|                 | s |   |           | e |        |     |     |          |
|                 | e |   |           | r |        |     |     |          |
|                 | s |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| #####           | # |   |           | # |        |     | ### |          |
| #  Hearing Aids | # |   |           | # |        |     | ### |          |
|                 | # |   |           | # |        |     |   W |          |
|                 | # |   |           | # |        |     | hee |          |
|                 | # |   |           | # |        |     | lch |          |
|                 | # |   |           | # |        |     | air |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 | C |   |           | C |        |     |     |          |
|                 | a |   |           | r |        |     |     |          |
|                 | n |   |           | u |        |     |     |          |
|                 | e |   |           | t |        |     |     |          |
|                 |   |   |           | c |        |     |     |          |
|                 |   |   |           | h |        |     |     |          |
|                 |   |   |           | e |        |     |     |          |
|                 |   |   |           | s |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######          |   |   | ####      |   |        | ##  |     |          |
| Translated Writ |   |   | ##  Trans |   |        | ### |     |          |
| ten Information |   |   | lator for |   |        | #   |     |          |
|                 |   |   |  Speaking |   |        | Oth |     |          |
|                 |   |   |           |   |        | er: |     |          |
|                 |   |   |           |   |        |     |     |          |
|                 |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+
| ######          |   |   |           |   |        |     |     |          |
| Does client hav |   |   |           |   |        |     |     |          |
| e a history of  |   |   |           |   |        |     |     |          |
| falls?  Yes  No |   |   |           |   |        |     |     |          |
|  Explain:       |   |   |           |   |        |     |     |          |
+-----------------+---+---+-----------+---+--------+-----+-----+----------+

Child/Adolescent Educational Assessment

+----------------+---+--------------+----------------+-----------------+
| ######         |   |              |                |                 |
| {#section-126} |   |              |                |                 |
|                |   |              |                |                 |
| **Current      |   |              |                |                 |
| educational    |   |              |                |                 |
| setting:**     |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| ######  Public | # |              | ##             | ######  Charter |
|                | # |              | ####  Boarding |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                |   |              |                |                 |
|                |   |              |                |                 |
|                | T |              |                |                 |
|                | r |              |                |                 |
|                | i |              |                |                 |
|                | b |              |                |                 |
|                | a |              |                |                 |
|                | l |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| #              | # |              | ######  BIA    | ###             |
| #####  Private | # |              |                | ###  Vocational |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                |   |              |                |                 |
|                |   |              |                |                 |
|                | H |              |                |                 |
|                | o |              |                |                 |
|                | m |              |                |                 |
|                | e |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| ###            | # |              | #              | ####            |
| ###  Alternate | # |              | #####  College | ##  Other       |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                | # |              |                |                 |
|                |   |              |                |                 |
|                |   |              |                |                 |
|                | G |              |                |                 |
|                | E |              |                |                 |
|                | D |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
|                |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| #####          |   | **Skipped a  |                |                 |
| # Current grad |   | grade or**   |                |                 |
| e level:       |   | **been held  |                |                 |
|                |   | back?**      |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **Any testing  |   |              |                |                 |
| for an IEP     |   |              |                |                 |
| (              |   |              |                |                 |
| Individualized |   |              |                |                 |
| Education      |   |              |                |                 |
| Plan)?** Yes   |   |              |                |                 |
| No             |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **History of   |   |              |                |                 |
| /or current    |   |              |                |                 |
| placement in   |   |              |                |                 |
| special        |   |              |                |                 |
| education?**   |   |              |                |                 |
|       **How    |   |              |                |                 |
| many hours per |   |              |                |                 |
| day?      **   |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **For learning |   |              |                |                 |
| problems?**    |   |              |                |                 |
| Yes No **For   |   |              |                |                 |
| behavior       |   |              |                |                 |
| problems?**    |   |              |                |                 |
| Yes No         |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **History of   |   |              |                |                 |
| hyperactivity  |   |              |                |                 |
| at school?**   |   |              |                |                 |
| Yes No         |   |              |                |                 |
| Comment:       |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **Ever been    |   |              |                |                 |
| expelled or    |   |              |                |                 |
| suspended?**   |   |              |                |                 |
| Yes No Reason: |   |              |                |                 |
|                |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **School       |   |              |                |                 |
| attendance     |   |              |                |                 |
| problems:**    |   |              |                |                 |
| Yes No         |   |              |                |                 |
| Comments:      |   |              |                |                 |
|                |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+
| **Other        |   |              |                |                 |
| edu            |   |              |                |                 |
| cation-related |   |              |                |                 |
| concerns:**    |   |              |                |                 |
|                |   |              |                |                 |
+----------------+---+--------------+----------------+-----------------+

**Leisure & Recreation**

+----------------------------+----+-----------------------------+----+
| **Which of the following   |    |                             |    |
| does the client do?        |    |                             |    |
| (Select all that apply)**  |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Spend Time with Friends    |    | Sports/Exercise             |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Classes                    |    | Dancing                     |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Time with Family           |    | Hobbies                     |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Work Part-Time             |    | Watch Movies/TV             |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Go "Downtown"              |    | Stay at Home                |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Listen to Music            |    | Spend Time at Clubs/Bars    |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| Go to Casinos              |    | Other:                      |    |
|                            |    |                             |    |
|                            |    |                             |    |
+----------------------------+----+-----------------------------+----+
| # What limits              |    |                             |    |
|  the client's leisure/recr |    |                             |    |
| eational activities?       |    |                             |    |
+----------------------------+----+-----------------------------+----+

**Family Social History**

+-----------------------------------------------------------------------+
| **Describe family relationships & desire for involvement in the       |
| treatment process:**                                                  |
|                                                                       |
| **Perceived level of support for treatment? (scale 1-5 with 5 being   |
| the most supportive)      **                                          |
+-----------------------------------------------------------------------+

+-----------------------------------------------------+--------+------+
| ### Psychological                                   | ##     | **   |
|                                                     | ## Yes | No** |
+-----------------------------------------------------+--------+------+
| Client accepts responsibility for creating his/her  |        |      |
| own feelings.                                       |        |      |
+-----------------------------------------------------+--------+------+
| Client accepts responsibility for his/her own       |        |      |
| actions.                                            |        |      |
+-----------------------------------------------------+--------+------+
| Client makes decisions with a minimum of stress and |        |      |
| worry.                                              |        |      |
+-----------------------------------------------------+--------+------+
| Client is able to express feelings of anger,        |        |      |
| disappointment, frustration, etc.                   |        |      |
+-----------------------------------------------------+--------+------+
| Client reports a stable emotional life.             |        |      |
|                                                     |        |      |
+-----------------------------------------------------+--------+------+
| Client feels enthusiastic about his/her life.       |        |      |
|                                                     |        |      |
+-----------------------------------------------------+--------+------+
| Client reports adequate energy level.               |        |      |
|                                                     |        |      |
+-----------------------------------------------------+--------+------+
| Client reports sleep is restful & adequate.         |        |      |
|                                                     |        |      |
+-----------------------------------------------------+--------+------+
| Client reports he/she feels positive about self.    |        |      |
|                                                     |        |      |
+-----------------------------------------------------+--------+------+
| **Comments:**                                       |        |      |
+-----------------------------------------------------+--------+------+

# Bereavement/Loss & Spiritual Awareness

+----------------------------------------------------------------------+
| # Please list                                                        |
| significant losses, deaths, abandonments, traumatic incidents:       |
+----------------------------------------------------------------------+
| #  {#section-127}                                                    |
|                                                                      |
| # Spiritual/Cultural Awareness & Practice                            |
+----------------------------------------------------------------------+
| # Knowledgeable                                                      |
| about traditions, spirituality, or religion?  Yes  No Comment:       |
+----------------------------------------------------------------------+
| # Prac                                                               |
| tices traditions, spirituality, or religion?  Yes  No Comment:       |
+----------------------------------------------------------------------+
| # How does client describe his/her spirituality?                     |
+----------------------------------------------------------------------+
| # Does client see a traditional healer?  Yes  No Comment:            |
+----------------------------------------------------------------------+

# Behavioral Assessment

<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 3%" />
<col style="width: 10%" />
<col style="width: 3%" />
<col style="width: 12%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 20%" />
<col style="width: 9%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><h6 id="section-128"></h6>
<h6 id="abuseaddiction-chemical-behavioral">Abuse/Addiction – Chemical
&amp; Behavioral</h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="drug">Drug</h6></td>
<td colspan="2"><h6 id="age-first-used">Age First Used</h6></td>
<td colspan="3"><h6 id="age-heaviest-use">Age Heaviest Use</h6></td>
<td colspan="2"><h6
id="recent-pattern-of-use-frequency-amount-etc">Recent Pattern of Use
(frequency &amp; Amount, etc)</h6></td>
<td><h6 id="date-last-used">Date Last Used</h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="alcohol-1">Alcohol</h6></td>
<td colspan="2"><h6 id="section-129">     </h6></td>
<td colspan="3"><h6 id="section-130">     </h6></td>
<td colspan="2"><h6 id="section-131">     </h6></td>
<td><h6 id="section-132">     </h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="cannabis">Cannabis</h6></td>
<td colspan="2"><h6 id="section-133">     </h6></td>
<td colspan="3"><h6 id="section-134">     </h6></td>
<td colspan="2"><h6 id="section-135">     </h6></td>
<td><h6 id="section-136">     </h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="cocaine">Cocaine</h6></td>
<td colspan="2"><h6 id="section-137">     </h6></td>
<td colspan="3"><h6 id="section-138">     </h6></td>
<td colspan="2"><h6 id="section-139">     </h6></td>
<td><h6 id="section-140">     </h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6
id="stimulants-crystal-speed-amphetamines-etc">Stimulants (crystal,
speed, amphetamines, etc)</h6></td>
<td colspan="2"><h6 id="section-141">     </h6></td>
<td colspan="3"><h6 id="section-142">     </h6></td>
<td colspan="2"><h6 id="section-143">     </h6></td>
<td><h6 id="section-144">     </h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="methamphetamine">Methamphetamine</h6></td>
<td colspan="2"><h6 id="section-145">     </h6></td>
<td colspan="3"><h6 id="section-146">     </h6></td>
<td colspan="2"><h6 id="section-147">     </h6></td>
<td><h6 id="section-148">     </h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="inhalants-gas-paint-glue-etc">Inhalants (gas,
paint, glue, etc)</h6></td>
<td colspan="2"><h6 id="section-149">     </h6></td>
<td colspan="3"><h6 id="section-150">     </h6></td>
<td colspan="2"><h6 id="section-151">     </h6></td>
<td><h6 id="section-152">     </h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6
id="hallucinogens-lsd-pcp-mushrooms-etc">Hallucinogens (LSD, PCP,
mushrooms, etc)</h6></td>
<td colspan="2"><h6 id="section-153">     </h6></td>
<td colspan="3"><h6 id="section-154">     </h6></td>
<td colspan="2"><h6 id="section-155">     </h6></td>
<td><h6 id="section-156">     </h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="opioids-heroin-narcotics-methadone-etc">Opioids
(heroin, narcotics, methadone, etc)</h6></td>
<td colspan="2"><h6 id="section-157">     </h6></td>
<td colspan="3"><h6 id="section-158">     </h6></td>
<td colspan="2"><h6 id="section-159">     </h6></td>
<td><h6 id="section-160">     </h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6
id="sedativehypnotics-valium-phenobarb-etc">Sedative/Hypnotics (Valium,
Phenobarb, etc)</h6></td>
<td colspan="2"><h6 id="section-161">     </h6></td>
<td colspan="3"><h6 id="section-162">     </h6></td>
<td colspan="2"><h6 id="section-163">     </h6></td>
<td><h6 id="section-164">     </h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6
id="designer-drugsother-herbal-steroids-cough-syrup-etc">Designer
Drugs/Other (herbal, Steroids, cough syrup, etc)</h6></td>
<td colspan="2"><h6 id="section-165">     </h6></td>
<td colspan="3"><h6 id="section-166">     </h6></td>
<td colspan="2"><h6 id="section-167">     </h6></td>
<td><h6 id="section-168">     </h6></td>
</tr>
<tr class="odd">
<td colspan="2"><h6 id="tobacco-smoke-chew">Tobacco (smoke,
chew)</h6></td>
<td colspan="2"><h6 id="section-169">     </h6></td>
<td colspan="3"><h6 id="section-170">     </h6></td>
<td colspan="2"><h6 id="section-171">     </h6></td>
<td><h6 id="section-172">     </h6></td>
</tr>
<tr class="even">
<td colspan="2"><h6 id="caffeine">Caffeine</h6></td>
<td colspan="2"><h6 id="section-173">     </h6></td>
<td colspan="3"><h6 id="section-174">     </h6></td>
<td colspan="2"><h6 id="section-175">     </h6></td>
<td><h6 id="section-176">     </h6></td>
</tr>
<tr class="odd">
<td colspan="7"><h6 id="ever-injected-drugs-yes-no">Ever injected Drugs?
Yes No</h6></td>
<td colspan="3"><h6 id="if-yes-which-ones">If Yes, Which ones?
     </h6></td>
</tr>
<tr class="even">
<td colspan="10"><h6 id="drug-of-choice">Drug of Choice?      </h6></td>
</tr>
<tr class="odd">
<td colspan="10"><h6 id="section-177"></h6>
<h6
id="consequences-as-a-result-of-drugalcohol-use-select-all-that-apply">Consequences
as a Result of Drug/Alcohol Use (select all that apply)</h6></td>
</tr>
<tr class="even">
<td><h6 id="hangovers"> Hangovers</h6></td>
<td colspan="4"><h6 id="dtsshakes"> DTs/Shakes</h6></td>
<td colspan="3"><h6 id="blackouts"> Blackouts</h6></td>
<td colspan="2"><h6 id="binges"> Binges</h6></td>
</tr>
<tr class="odd">
<td><h6 id="overdoses"> Overdoses</h6></td>
<td colspan="4"><h6 id="increased-tolerance"> Increased Tolerance </h6>
<h6 id="need-more-to-get-high"> (need more to get high)</h6></td>
<td colspan="3"><h6 id="gi-bleeding"> GI Bleeding</h6></td>
<td colspan="2"><h6 id="liver-disease"> Liver Disease</h6></td>
</tr>
<tr class="even">
<td><h6 id="sleep-problems"> Sleep Problems</h6></td>
<td colspan="4"><h6 id="seizures-1"> Seizures</h6></td>
<td colspan="3"><h6 id="relationship-problems"> Relationship
Problems</h6></td>
<td colspan="2"><h6 id="left-school"> Left School</h6></td>
</tr>
<tr class="odd">
<td><h6 id="lost-job"> Lost Job</h6></td>
<td colspan="4"><h6 id="duis"> DUIs</h6></td>
<td colspan="3"><h6 id="assaults"> Assaults</h6></td>
<td colspan="2"><h6 id="arrests"> Arrests</h6></td>
</tr>
<tr class="even">
<td><h6 id="incarcerations"> Incarcerations</h6></td>
<td colspan="4"><h6 id="homicide"> Homicide</h6></td>
<td colspan="5"><h6 id="other-7"> Other:      </h6></td>
</tr>
<tr class="odd">
<td colspan="5"><h6 id="longest-period-of-sobriety">Longest Period of
Sobriety?      </h6></td>
<td colspan="5"><h6 id="how-long-ago">How long ago?      </h6></td>
</tr>
<tr class="even">
<td colspan="10"><h6 id="triggers-to-use-list-all-that-apply">Triggers
to use (list all that apply):      </h6></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Has client traded sex for drugs?</strong> No
Yes, explain:      </td>
</tr>
<tr class="even">
<td colspan="10"><strong>Has client been tested for HIV?</strong> Yes
No</td>
</tr>
<tr class="odd">
<td colspan="6"><strong>If yes, date of last test:</strong>      </td>
<td colspan="4"><strong>Results:</strong>      </td>
</tr>
<tr class="even">
<td colspan="10"><strong>Has client had any of the following problem
gambling behaviors?</strong> Select all that apply:</td>
</tr>
<tr class="odd">
<td colspan="3"> Gambled longer than planned</td>
<td colspan="7"> Gambled until last dollar was gone</td>
</tr>
<tr class="even">
<td colspan="3"> Lost sleep thinking of gambling</td>
<td colspan="7"> Used income or savings to gamble while letting bills go
unpaid</td>
</tr>
<tr class="odd">
<td colspan="3"> Borrowed money to gamble</td>
<td colspan="7"> Made repeated, unsuccessful attempts to stop
gambling</td>
</tr>
<tr class="even">
<td colspan="3"> Been remorseful after gambling</td>
<td colspan="7"> Broken the law or considered breaking the law to
finance gambling</td>
</tr>
<tr class="odd">
<td colspan="3"> Other:      </td>
<td colspan="7"> Gambled to get money to meet financial obligations</td>
</tr>
</tbody>
</table>

+-----------------------+-----------------------+-----------------------+
| **Risk                |                       |                       |
| Taking/Impulsive      |                       |                       |
| Behavior              |                       |                       |
| (current/past) --     |                       |                       |
| select all that       |                       |                       |
| apply:**              |                       |                       |
+-----------------------+-----------------------+-----------------------+
| ##                    | ######  Shoplifting   | ###                   |
| ####  Unprotected sex |                       | ###  Reckless driving |
+-----------------------+-----------------------+-----------------------+
| ###                   | ######  Drug Dealing  | ######                |
| ###  Gang Involvement |                       | Carrying/using weapon |
+-----------------------+-----------------------+-----------------------+
| ######  Ot            |                       |                       |
| her:       {#other-8} |                       |                       |
+-----------------------+-----------------------+-----------------------+

**Abuse/Neglect/Exploitation Assessment**

+-------------------------------+-----------------+--------+----------+
| ###### Hi                     |                 |        |          |
| story of neglect (emotional,  |                 |        |          |
| nutritional, medical, educati |                 |        |          |
| onal) or exploitation?        |                 |        |          |
|                               |                 |        |          |
| ######                        |                 |        |          |
| If yes, please explain.       |                 |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Has clie               |                 |        |          |
| nt been abused at any time in |                 |        |          |
|  the past or present by famil |                 |        |          |
| y, significant others, or any |                 |        |          |
| one else?)  No  Yes, explain: |                 |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Type of Abuse          | ###### By Whom  | ####   | ######   |
|                               |                 | ## Cli | Currentl |
|                               |                 | ent's  | y Occurr |
|                               |                 | Age(s) | ing? Y/N |
+-------------------------------+-----------------+--------+----------+
| ###### Verbal Putdowns        | ######          | ###    | ###      |
|                               |  {#section-178} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-180} |
|                               |                 | n-179} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Being threatened       | ######          | ###    | ###      |
|                               |  {#section-181} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-183} |
|                               |                 | n-182} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Made to feel afraid    | ######          | ###    | ###      |
|                               |  {#section-184} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-186} |
|                               |                 | n-185} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Pushed                 | ######          | ###    | ###      |
|                               |  {#section-187} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-189} |
|                               |                 | n-188} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Shoved                 | ######          | ###    | ###      |
|                               |  {#section-190} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-192} |
|                               |                 | n-191} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Slapped                | ######          | ###    | ###      |
|                               |  {#section-193} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-195} |
|                               |                 | n-194} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Kicked                 | ######          | ###    | ###      |
|                               |  {#section-196} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-198} |
|                               |                 | n-197} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Strangled              | ######          | ###    | ###      |
|                               |  {#section-199} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-201} |
|                               |                 | n-200} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Hit                    | ######          | ###    | ###      |
|                               |  {#section-202} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-204} |
|                               |                 | n-203} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Forced or              | ######          | ###    | ###      |
|  coerced into sexual activity |  {#section-205} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-207} |
|                               |                 | n-206} |          |
+-------------------------------+-----------------+--------+----------+
| ###### Other       {#other-9} | ######          | ###    | ###      |
|                               |  {#section-208} | ###    | ###      |
|                               |                 |     {# |   {#sect |
|                               |                 | sectio | ion-210} |
|                               |                 | n-209} |          |
+-------------------------------+-----------------+--------+----------+
| ######  {#section-211}        | ######          |        |          |
|                               |  {#section-212} |        |          |
| ###                           |                 |        |          |
| ### Was it reported?  Yes  No | ######          |        |          |
|                               |  To whom?       |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Outcome                |                 |        |          |
|                               |                 |        |          |
|                               |                 |        |          |
+-------------------------------+-----------------+--------+----------+
| ###### Has client ever wi     |                 |        |          |
| tnessed abuse or family viole |                 |        |          |
| nce?  No  Yes, explain:       |                 |        |          |
+-------------------------------+-----------------+--------+----------+

+-----------------------------------------------------+--------+------+
| # Strengths/Weaknesses                              | *      | **   |
|                                                     | *Yes** | No** |
+-----------------------------------------------------+--------+------+
| Client is able to seek out appropriate resources    |        |      |
| for assistance with identified problems.            |        |      |
+-----------------------------------------------------+--------+------+
| Client is able to identify both his/her strengths   | **     | *    |
| and weaknesses.                                     |     ** | *    |
|                                                     |        |   ** |
+-----------------------------------------------------+--------+------+
| **Comments:**                                       |        |      |
+-----------------------------------------------------+--------+------+
| **Strengths/Resources (enter score if present)** 1  |        |      |
| = Adequate, 2 = Above Average, 3 = Exceptional      |        |      |
|                                                     |        |      |
|   -------------------                               |        |      |
| ---------- -------------------- ------------------- |        |      |
|        Family Suppo                                 |        |      |
| rt                Social Support       Relationship |        |      |
|                                                     |        |      |
|                      Systems              Stability |        |      |
|                                                     |        |      |
|        Intellect                                    |        |      |
| ual/Cognitive        Coping Skills &      Parenting |        |      |
|   Skills                                            |        |      |
|                         Resiliency           Skills |        |      |
|                                                     |        |      |
|        Socio-Eco                                    |        |      |
| nomic Stability      Communication        Insight & |        |      |
|                                                     |        |      |
|                    Skills               Sensitivity |        |      |
|                                                     |        |      |
|        Maturity & J                                 |        |      |
| udgment           Motivation for       Other:       |        |      |
|                                                     |        |      |
| Skills                        Help                  |        |      |
|   -------------------                               |        |      |
| ---------- -------------------- ------------------- |        |      |
|                                                     |        |      |
| **Comments:**                                       |        |      |
+-----------------------------------------------------+--------+------+
| **Describe appropriateness & level of need for the  |        |      |
| family's participation:**                           |        |      |
+-----------------------------------------------------+--------+------+

#   {#section-213}

Mental Status Exam

<table>
<colgroup>
<col style="width: 16%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 20%" />
</colgroup>
<tbody>
<tr class="odd">
<td><h2 id="category"><strong>Category</strong></h2></td>
<td colspan="18"><h3 id="selections">Selections</h3></td>
</tr>
<tr class="even">
<td colspan="19"><strong>GENERAL OBSERVATIONS</strong></td>
</tr>
<tr class="odd">
<td><h2 id="appearance"><strong>Appearance</strong></h2></td>
<td colspan="3"> Well groomed</td>
<td colspan="6"> Unkempt</td>
<td colspan="6"> Disheveled</td>
<td colspan="3"> Malodorous</td>
</tr>
<tr class="even">
<td><strong>Build</strong></td>
<td colspan="3"> Average</td>
<td colspan="6"> Thin</td>
<td colspan="6"> Overweight</td>
<td colspan="3"> Obese</td>
</tr>
<tr class="odd">
<td rowspan="2"><strong>Demeanor</strong></td>
<td colspan="3"> Cooperative</td>
<td colspan="6"> Hostile</td>
<td colspan="6"> Guarded</td>
<td colspan="3"> Withdrawn</td>
</tr>
<tr class="even">
<td colspan="7"> Preoccupied</td>
<td colspan="7"> Demanding</td>
<td colspan="4"> Seductive</td>
</tr>
<tr class="odd">
<td><strong>Eye Contact</strong></td>
<td colspan="7"> Average</td>
<td colspan="7"> Decreased</td>
<td colspan="4"> Increased</td>
</tr>
<tr class="even">
<td><strong>Activity</strong></td>
<td colspan="7"> Average</td>
<td colspan="7"> Decreased</td>
<td colspan="4"> Increased</td>
</tr>
<tr class="odd">
<td rowspan="3"><strong>Speech</strong></td>
<td colspan="3"> Clear</td>
<td colspan="6"> Slurred</td>
<td colspan="6"> Rapid</td>
<td colspan="3"> Slow</td>
</tr>
<tr class="even">
<td colspan="3"> Pressured</td>
<td colspan="6"> Soft</td>
<td colspan="6"> Loud</td>
<td colspan="3"> Monotone</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td colspan="19"><strong>THOUGHT CONTENT</strong></td>
</tr>
<tr class="odd">
<td><strong>Delusions</strong></td>
<td colspan="4"> None Reported</td>
<td colspan="6"> Grandiose</td>
<td colspan="6"> Persecutory</td>
<td colspan="2"> Somatic</td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td colspan="6"> Bizarre</td>
<td colspan="7"> Nihilist</td>
<td colspan="5"> Religious</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td rowspan="4"><strong>Other</strong></td>
<td colspan="4"> None Reported</td>
<td colspan="6"> Poverty of Content</td>
<td colspan="6"> Obsessions</td>
<td colspan="2"> Compulsions</td>
</tr>
<tr class="odd">
<td colspan="4"> Phobias</td>
<td colspan="6"> Guilt</td>
<td colspan="6"> Anhedonia</td>
<td colspan="2">Thought Insertion</td>
</tr>
<tr class="even">
<td colspan="10"> Ideas of Reference</td>
<td colspan="8"> Thought Broadcasting</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td rowspan="2"><strong>Self Abuse</strong></td>
<td colspan="11"> None Reported</td>
<td colspan="7"> Self Mutilization</td>
</tr>
<tr class="odd">
<td colspan="11"> Suicidal (assess lethality if present)</td>
<td colspan="6"> Intent</td>
<td> Plan</td>
</tr>
<tr class="even">
<td><strong>Aggressive</strong></td>
<td colspan="5"> None Reported</td>
<td colspan="13"> Aggressive (assess lethality of present)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="11"> Intent</td>
<td colspan="7"> Plan</td>
</tr>
<tr class="even">
<td colspan="19"><strong>PERCEPTION</strong></td>
</tr>
<tr class="odd">
<td rowspan="3"><strong>Hallucinations</strong></td>
<td colspan="6"> None Reported</td>
<td colspan="7"> Auditory</td>
<td colspan="5"> Visual</td>
</tr>
<tr class="even">
<td colspan="6"> Olfactory</td>
<td colspan="7"> Gustatory</td>
<td colspan="5"> Tactile</td>
</tr>
<tr class="odd">
<td colspan="18">Describe:      </td>
</tr>
<tr class="even">
<td><strong>Other</strong></td>
<td colspan="4"> None Reported</td>
<td colspan="6"> Illusions</td>
<td colspan="6"> Depersonalization</td>
<td colspan="2"> Derealization</td>
</tr>
<tr class="odd">
<td colspan="19"><strong>THOUGHT PROCESS</strong></td>
</tr>
<tr class="even">
<td colspan="2"> Logical</td>
<td colspan="7"> Goal Oriented</td>
<td colspan="6"> Circumstantial</td>
<td colspan="4"> Tangential</td>
</tr>
<tr class="odd">
<td colspan="2"> Loose</td>
<td colspan="7"> Rapid Thoughts</td>
<td colspan="6"> Incoherent</td>
<td colspan="4"> Concrete</td>
</tr>
<tr class="even">
<td colspan="2"> Blocked</td>
<td colspan="7"> Flight of Ideas</td>
<td colspan="6"> Perserverative</td>
<td colspan="4"> Derailment</td>
</tr>
<tr class="odd">
<td colspan="19">Describe:      </td>
</tr>
<tr class="even">
<td colspan="19"><strong>MOOD</strong></td>
</tr>
<tr class="odd">
<td colspan="3"> Euthymic</td>
<td colspan="10"> Depressed</td>
<td colspan="6"> Anxious</td>
</tr>
<tr class="even">
<td colspan="3"> Angry</td>
<td colspan="10"> Euphoric</td>
<td colspan="6"> Irritable</td>
</tr>
<tr class="odd">
<td colspan="19"><strong>AFFECT</strong></td>
</tr>
<tr class="even">
<td colspan="2"> Flat</td>
<td colspan="7"> Inappropriate</td>
<td colspan="6"> Labile</td>
<td colspan="4"> Blunted</td>
</tr>
<tr class="odd">
<td colspan="3"> Congruent with Mood</td>
<td colspan="10"> Full</td>
<td colspan="6"> Constricted</td>
</tr>
<tr class="even">
<td colspan="19"><strong>BEHAVIOR</strong></td>
</tr>
<tr class="odd">
<td colspan="3"> No behavior issues</td>
<td colspan="10"> Assaultive</td>
<td colspan="6"> Resistant</td>
</tr>
<tr class="even">
<td colspan="3"> Aggressive</td>
<td colspan="10"> Agitated</td>
<td colspan="6"> Hyperactive</td>
</tr>
<tr class="odd">
<td colspan="3"> Restless</td>
<td colspan="10"> Sleepy</td>
<td colspan="6"> Intrusive</td>
</tr>
<tr class="even">
<td colspan="19"><strong>MOVEMENT</strong></td>
</tr>
<tr class="odd">
<td colspan="2"> Akasthisia</td>
<td colspan="7"> Dystonia</td>
<td colspan="6"> Tardive Dyskinesia</td>
<td colspan="4"> Tics</td>
</tr>
<tr class="even">
<td colspan="19">Describe:      </td>
</tr>
<tr class="odd">
<td colspan="19"><strong>COGNITION</strong></td>
</tr>
<tr class="even">
<td rowspan="3"><strong>Impairment of:</strong></td>
<td colspan="8"> None Reported</td>
<td colspan="6"> Orientation</td>
<td colspan="4"> Memory</td>
</tr>
<tr class="odd">
<td colspan="8"> Attention/Concentration</td>
<td colspan="10"> Ability to Abstract</td>
</tr>
<tr class="even">
<td colspan="18">Describe:      </td>
</tr>
<tr class="odd">
<td><strong>Intelligence Estimate</strong></td>
<td colspan="4"> Mental Retardation</td>
<td colspan="6"> Borderline</td>
<td colspan="6"> Average</td>
<td colspan="2"> Above Average</td>
</tr>
<tr class="even">
<td colspan="5"><strong>IMPULSE CONTROL</strong></td>
<td colspan="6"> Good</td>
<td colspan="6"> Poor</td>
<td colspan="2"> Absent</td>
</tr>
<tr class="odd">
<td colspan="5"><strong>INSIGHT</strong></td>
<td colspan="6"> Good</td>
<td colspan="6"> Poor</td>
<td colspan="2"> Absent</td>
</tr>
<tr class="even">
<td colspan="5"><strong>JUDGMENT</strong></td>
<td colspan="6"> Good</td>
<td colspan="6"> Poor</td>
<td colspan="2"> Absent</td>
</tr>
</tbody>
</table>

  ----------------- -------------- --------- ------------ -------------- --------------
  **RISK                                                                 
  ASSESSMENT**                                                           

  **Risk to Self**  Low            Medium                 High           Chronic

  **Risk to         Low            Medium                 High           Chronic
  Others**                                                               

  **Serious current                                                      
  risk of any of                                                         
  the following:                                                         
  (Immediate                                                             
  response                                                               
  needed)**                                                              

  **Abuse or Family                          **Abuse or                  
  Violence** Yes No                          Family                      
                                             Violence**                  
                                             Yes No                      

  **Psychotic or                                                         
  Severely                                                               
  Psychologically                                                        
  Disabled** Yes No                                                      

  **Is there a                               **Any other                 
  handgun in the                             weapons?**                  
  home?** Yes No                             Yes No                      

  **Plan:**                                                              

  **Safety Plan                                                          
  Reviewed** Yes No                                                      
  ----------------- -------------- --------- ------------ -------------- --------------

Diagnoses and Interpretive Summary

+--------+-------------------------------------------------------------+
| ####   |                                                             |
| ## Bio |                                                             |
| psycho |                                                             |
| social |                                                             |
|  formu |                                                             |
| lation |                                                             |
+--------+-------------------------------------------------------------+
| ####   |                                                             |
| ##  {# |                                                             |
| sectio |                                                             |
| n-214} |                                                             |
|        |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| ##     |                                                             |
| #### D |                                                             |
| SM IV- |                                                             |
| TR Pro |                                                             |
| vision |                                                             |
| al Dia |                                                             |
| gnoses |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| I**    |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| II**   |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| III**  |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| IV**   |                                                             |
|        |                                                             |
+--------+-------------------------------------------------------------+
| **Axis |                                                             |
| V**    |                                                             |
+--------+-------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # Treatment Acceptance/Resistance                                     |
+-----------------------------------------------------------------------+
| **Client accepts problem?** No Yes Comment:                           |
+-----------------------------------------------------------------------+
| **Client recognizes need for treatment?** No Yes Comment:             |
+-----------------------------------------------------------------------+
| **Client minimizes or blames others?** No Yes Comment:                |
+-----------------------------------------------------------------------+
| **External motivation is primary?** No Yes Comment:                   |
+-----------------------------------------------------------------------+

# Preliminary Treatment Plan & Referrals 

+-----------------+-----------------+--------+-----+------------------+
| ####            |                 |        |     |                  |
| ## Preliminary  |                 |        |     |                  |
| Biopsychosocial |                 |        |     |                  |
|  Treatment Plan |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| **Biological:** |                 |        |     |                  |
|                 |                 |        |     |                  |
|                 |                 |        |     |                  |
| **P             |                 |        |     |                  |
| sychological:** |                 |        |     |                  |
|                 |                 |        |     |                  |
|                 |                 |        |     |                  |
| **Social/E      |                 |        |     |                  |
| nvironmental:** |                 |        |     |                  |
|                 |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| #               |                 |        |     |                  |
| ##### Referrals |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| Psychiatrist    | Psychologist    |        |     | Spiritual        |
|                 |                 | M      |     | Counselor        |
|                 |                 | edical |     |                  |
|                 |                 | Pr     |     |                  |
|                 |                 | ovider |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| Benefits        | Nutritionist    |        |     | Vocational       |
| Coordinator     |                 | Re     |     | Counselor        |
|                 |                 | habili |     |                  |
|                 |                 | tation |     |                  |
+-----------------+-----------------+--------+-----+------------------+
| Social Worker   | Community       |        |     |                  |
|                 | Agency:         |        | Oth |                  |
|                 |                 |        | er: |                  |
|                 |                 |        |     |                  |
|                 |                 |        |     |                  |
+-----------------+-----------------+--------+-----+------------------+

Physical Fitness (Optional)

+-----------------------------------------------------------------------+
| ######  {#section-215}                                                |
|                                                                       |
| ###### Physical Activity (please sel                                  |
| ect one of the following based on activity level for the past month): |
|                                                                       |
| > Avoids walking or exertion, e.g. always uses elevator, drives       |
| > whenever possible instead of                                        |
| >                                                                     |
| > walking.                                                            |
| >                                                                     |
| > Walks for pleasure, routinely uses stairs, occasionally exercises   |
| > sufficiently to cause heavy                                         |
| >                                                                     |
| > breathing or perspiration.                                          |
| >                                                                     |
| > Participates regularly in recreation or work requiring **modest     |
| > physical activity** such as golf,                                   |
| >                                                                     |
| > horseback riding, calisthenics, gymnastics, table tennis, bowling,  |
| > weight lifting, and yard work.                                      |
| >                                                                     |
| > 10-60 minutes per week                                              |
| >                                                                     |
| > More than one hour per week                                         |
| >                                                                     |
| > Participates regularly in **heavy physical exercise,** such as      |
| > running, jogging, swimming, cycling,                                |
| >                                                                     |
| > rowing, skipping rope, running in place or engaging in vigorous     |
| > aerobic activity such as tennis,                                    |
| >                                                                     |
| > basketball or handball.                                             |
| >                                                                     |
| > Runs less than a mile a week or engages in other exercise for less  |
| > than 30 minutes                                                     |
| >                                                                     |
| > per week                                                            |
| >                                                                     |
| > Runs 1-5 miles per week or engages in other exercise for 30-60      |
| > minutes per week                                                    |
| >                                                                     |
| > Runs 5-10 miles per week or engages in other exercise for 1-3 hours |
| > per week                                                            |
| >                                                                     |
| > Runs more than 10 miles per week or engages in other exercise for   |
| > more than 3 hours                                                   |
| >                                                                     |
| > per week                                                            |
+-----------------------------------------------------------------------+