Académique Documents
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CLIENT HISTORY
Name___________________________________________________________Age___________Sex_________
Marital status_______________________________________________________________________________
Living arrangements__________________________________________________________________________
Occupation_________________________________________________________________________________
Education__________________________________________________________________________________
Religious affiliation___________________________________________________________________________
A. Statement in the client’s own words of why he or she is hospitalized or seeking help
___________________________________________________________________________________________
___________________________________________________________________________________________
B. Recent difficulties/alterations
in_____________________________________________________________
1. Relationships
3. Behavior
C. Increased feeling of
_______________________________________________________________________
1. Depression
2. Anxiety
3. Hopelessness
4. Being overwhelmed
5. Suspiciousness
6. Confusion
1. Constipation
2. Insomnia
3. Lethargy
5. Palpitations
B. Educational
background___________________________________________________________________
C. Occupational
background__________________________________________________________________
1. If employed, where?______________________________________________________________________
4. Special skills____________________________________________________________________________
D. Social patterns
1. Describe friends_________________________________________________________________________
E. Sexual patterns
1. Sexually active?_________________________________________________________________________
2. Sexual orientation_______________________________________________________________________
3. Sexual difficulties________________________________________________________________________
2. What herbal or over the counter medications does the client take?
________________________________
4. How many drinks of alcohol does the client take per day?
_______________________________________
Per week__________________________________________________________________________________
A. Childhood
4. Who was in the home when the client was growing up?
___________________________________________
B. Adolescence
C. Use of drugs
Prescription_______________________Street_____________________By whom?
______________________
E. Was there an unusual or outstanding event the client would like to mention?
___________________________
____________________________________________________________________________________________
A. Appearance
Physical handicaps__________________________________________________________________________
Dress: Appropriate__________________________Sloppy____________________________
Grooming: Neat____________________________Poor______________________________
B. Behavior
Restless__________________Agitated___________________Rapid________________Slurred__________
___
Mannerisms_____________________Facial
expressions________________________Other________________
C. Speech
Clear_________________Mumbled______________Rapid________________Lethargic________________
___
Constant________________Mute or silent____________________Barriers in
communications_____________
D. Mood
What mood does the client convey?
_____________________________________________________________
__________________________________________________________________________________________
E. Affect
__________________________________________________________________________________________
F. Thought process
1. Characteristics
Concrete thinking_____________Confabulation________________
_______________________________________________________________________________________
2. Cognitive ability
Proverbs: Concrete___________Abstract_____________
Serial sevens: How far does the client go?_____________Can the client do simple math?
__________
Orientation to time?_____________Place?________________Person?____________________
G. Thought content
Describe_______________________________________________________________________________
______________________________________________________________________________________
3. Insight: Does the client have hallucinations?__________Delusions?________________
Obsessions?_____________Rituals?_____________Phobias?_____________Grandiosity?
____________
Religiosity?_____________Worthlessness?_______________
Describe______________________________________________________________________________
H. Spiritual assessment
_____________________________________________________________________________________
2. Do the client’s religious or spiritual beliefs influence the way the client takes care of
himself or herself or his or her illness?________ How?
_________________________________________________________________
I. Cultural influences
2. Has the client tried any cultural remedies or practices for his or her condition? If so, what?
_____________
_______________________________________________________________________________________
_______________________________________________________________________________________