01. Date of Assessment
Date Begin Thu 21st of Jun, 2012
Date End Fri 22nd of Jun, 2012
02. User Information
Disclaimer yes
Research Consent yes
Truthful Reporting yes
03. Identification
Last Name de-identified
First Name de-identified
Nickname de-identified
Date of Birth de-identified
Age de-identified
Gender male
Street Address de-identified
City de-identified
State de-identified
Zip Code de-identified
Contact Numbers de-identified
Email Address de-identified
Handedness left handed
Race or Ethnicity white or caucasian
Preferred Language English
Form Completer last name de-identified
First Name of Person completing the Form de-identified
Relationship to patient biological mother
Who will bring the patient to the interview? biological mother, biological father
Referred for evaluation yes
Referral source psychologist
04. Presenting Problem
Chief Complaint Mood instability, moody or crying spells, or giggly
05. History of Present Illness
How long has the Chief Complaint been present 5 or more years Has the Chief Complaint worsened over time yes
How often does the Chief Complaint occur Several times a day.
Has a clinician been seen regarding the Chief Complaint yes
Name of Clinician(s) seen de-identified
What triggered the Chief Complaint unknown or not sure What makes the Chief Complaint better current medication
What makes the Chief Complaint worse past medication, school, fears, other
Example of current behavior When even the smallest things happen that he doesn't like he'll go into a tantrum with extreme crying and throwing himself onto the floor.
Secondary Complaints 1. Difficulty paying attention
2. Irritability, anger, rages 3. Violent behavior
4. Anxiety or excessive worries 5. Academic/School-related problems
6. Obsessed, stubborn, rigid, set in their ways, picky, doing things over and over 7. Odd, strange or unusual behavior
8. Not talking or not communicating as expected 9. Failed to develop age appropriate relationships 10. (Child only) Wets bed or underwear or soils underwear 11. Abnormal movements
12. Lack of ability to genuine bond with caregivers and/or excessively friendly with strangers
13. Very scared about certain things, people, animals, places, weather, blood, heights, enclosed places, choking, illness, etc
14. Very uncomfortable in social situations, public engagements, or refusing to go to school
15. Severe problems controlling urges (pulling hair, setting fires, gambling, stealing, fighting, playing video or computer games)
Not Selected Secondary Complaints 2. Hyperactivity
Not Selected Secondary Complaints 3. Mood instability, moody or crying spells, or giggly 4. Sleep difficulties
5. Depression or being withdrawn 6. Suicidal thoughts or behavior
7. Eating difficulties or likes to eat unusual things 8. Hearing voices that others cannot hear
9. Abuses nicotine, and/or alcohol, and/or drugs, and/or pills, and/or inhalants 10. Legal problems
11. (Child only) Bonding problems with caregivers due to history of neglect 12. Difficulty remembering familiar people or events, not feeling like his/her self, time loss, like in trance
13. Experienced traumatic event or victim of abuse 14. Screening
SYMPTOMS
Inattention/Hyperactivity/Impulsivity
1a. Fails to pay attention to details 9
2a. Has difficulty paying attention 9
3a. Does not seem to listen when spoken to directly 8 4a. Does not follow through on directions 9
5a. Difficulty organizing tasks 10
6a. Avoids tasks that require mental effort 10 7a. Loses things necessary for activities 9
8a. Forgetful in daily activities 8
9a. Easily distracted 8
Difficulty focusing when reading 8
Chronic procrastination 10
Difficulty prioritizing 9
Many activities at once 6
Difficulty multi-tasking 9
Difficulty managing time 9
Thoughts often bounce from one to another 8
Many ideas at one time 8
Inattention/Hyperactivity/Impulsivity
Easily frustrated 10
Impatient 9
Work harder than peers 6
More determined than average person 1
People think I am lazy 6
Underachieved academically 5
Lack of motivation 8
Symptoms present for 6 months yes
1b. Often fidgets or squirms 9
2b. Difficulty remaining seated 4
3b. Runs or climbs excessively 5
4b. Difficulty performing activities quietly 8 5b. Often "driven by a motor" (on the go) 7
6b. Talks excessively 6
7b. Answers before questions are completed 7 8b. Difficulty waiting for his or her turn 6 9b. Often interrupts or intrudes on others 7
Have poor handwriting 10
Impulsive behavior 8
Intolerance to boredom 2
Accident prone 5
Have poor hazard perception 6
Frequent search for high stimulation 8
Difficulty waking up in the morning yes
Hyperactive symptoms present for 6 months yes
Opositional Defiant Disorder
Opositional Defiant Disorder
6. Easily annoyed, bothered or upset by others 8
7. Often angry and resentful 9
8. Often spiteful or vindictive 7
Has the defiant or hostile behavior been present for at least six months?
yes
Conduct Disorder
1. Often threatens family members 2
2. Initiates physical fights or provokes physical fights 1 3. Ever used weapons that can cause bodily harm 1
4. Physically abusive 1
5. Often cruel to animals 0
6. Stolen while confronting a victim 0 7. Deliberately engaged in setting fires 0 8. Ever forced someone into performing a sexual act or
shown inappropriate sexual behavior
0 9. Destroy property by punching or kicking doors and walls or constantly throwing things
1 10. Ever broken into someone's house or car 0 11. Lies to obtain goods or to avoid obligations 10
12. Shoplifts or takes things 1
13. Stays out all night 0
14. Runs away from home 0
15. Truant from school 0
Have symptoms been present for 6 months or longer yes
Social Phobia
1. Fearful or stressful of social situations 7
2. Persistent fear of situations 7
3. Avoids social situations 6
4. Fear is unreasonable 5
Panic
Has experienced a panic attack unknown
Separation Anxiety Disorder
1. Worries that parent or guardian will be hurt or leave and not return
1 2. Often becomes upset when separated from parents, cry or have a temper tantrum when he or she is separated from mother, father or caregiver
1
3. Often avoids going to school to stay home with parent or guardian
1 4. Worries about being left alone at home or with a sitter 0 5. Afraid to go to sleep without his or her parent or guardian nearby
0 6. Has recurring nightmares of separation from parent or guardian
0 7. Often feel sick when away from home or separated from parent or guardian
0 8. Worries that some disaster will separate him or her from parent or guardian
0
Duration yes
Overanxious/Generalized Anxiety Disorder
Experience excessive worries, restlessness or feeling on edge for longer than a six-month periodyes 1. Gets tired easily, often feels exhausted, or becomes easily fatigued
1 2. Has difficulty concentrating or mind goes blank 8 3. Gets very irritable due to excessive worries or fears, and often feels cranky
5
4. Experiences frequent body aches 0
5. Experiences significant changes in sleep due to excessive worries
3
Overanxious/Generalized Anxiety Disorder
6. Has difficulty controlling worries 5
Post Traumatic Stress Disorder
Ever experienced a traumatic event no
Major Depression and Suicidality
Has been depressed 0
Depression has been present for two weeks or more at any time
no Has experienced depressive episodes in the past no
Feelings of hopelessness 7
Recurrent thoughts of death 1
Shows less interest or enjoyment in activities 1
Significant weight change 1
Weight lost or gained Lost 10 pounds from taking Orap medication.
Significant change in his or her sleep pattern 1
Psychomotor retardation 0
Often fatigued or tired for no apparent reason 1
Often feels worthless or guilty 6
Lessened ability to concentrate 9
Current symptoms present for 2 weeks or more yes
Thoughts about death, killing or harming self thinking about harming self without killing self Ever done anything to harm or kill self no
Last time wanted to die within last 12 months
How often thinks about dying rarely
Reasons wanting to die to get sympathy, rage or anger, feeling rejected, bullied or harassed at work or school, other
Other reasons wanting to die Unknown
Have plan to kill self no plan
Has difficulty controlling thoughts about wanting to diea no difficulty
Manic Episode
Manic Episode
Severe irritability during manic episode 7
Decreased need for sleep 1
More talkative than usual 5
Flight of ideas (jumps from one topic to another) 5
Distractibility 4
Increase in goal-directed activity (leaving several projects unfinished)
6 Excessive pleasurable activities with high risk of painful
consequences
1
Duration of last manic episode no manic episode
Obsessive Compulsive Disorder
Feels very stressed, anxious, frustrated, or angry yes Gets ideas stuck in his or her head yes
More picky than most people yes
Recurrent and persistent thoughts, impulses or images yes Description of recurrent and persistent thoughts, impulses or images
Impulses to make noises and movements (Tourette's). Repeats questions just asked to him. Fixates on certain things, such as trains, weather, puppies. Constantly have to watch where he goes to the bathroom. He urinates in inappropriate places such as the bathtub, floor, or on shelves in the bathroom. It doesn't occur regularly but rather every few months or so.
Insight about obsessive thoughts, impulses, and images being unreasonable
no 1. Difficulty controlling recurrent thoughts 7 2. Frequency of persistent thoughts 6 3. Severity of persistent or recurring thoughts 7 Repetitive or compulsive behaviors no
Anorexia Nervosa
1. Unusually thin or underweight 1
Bulimia Nervosa
1. Consumes a large amount of food in a short period of time
0
Learning Disabilities
1. Reading problems 6 2. Mathematics problems 1 3. Spelling problems 0 4. Writing problems 10 5. Slow learner 4Sleep Disorder
1. Difficulty falling asleep 1
2. Difficulty maintaining sleep 1
3. Fatigue 1
4. Excessive sleep during the day 0
5. Sudden urges to sleep during the daytime 0
6. Snored for at least one month 0
7. Stopped breathing while sleeping 0
8. Sleep walking 0 9. Sleep talking 0 10. Nightmares 0
Schizophrenia
Delusions no Hallucinations yes Hallucinations Severity 2 Catatonic Behavior 2Explain Disorganized Behavior no
Negative Symptoms 1
Explain Avolition or Alogia 1
Explain Blunted Affect 1
Explain Indifference 1
Explain Social or Emotional Withdrawal yes
Disorganized Speech yes
Impulse Control Disorder
1. Hair pulling 0
2. Picking at skin, scalp or nails 3
3. Head banging 0
4. Steals 0
5. Starts fires 0
6. Gambling 0
Communication Disorder
1. Speech or language problems 2
2. Stuttering 0
3. Difficulty pronouncing words 1
4. Difficulty comprehending (understanding) spoken words 1 5. Difficulty expressing self verbally 2
Specific Phobia
1. Phobia - Animal type 1
2. Phobial - Natural environment 5
3. Phobia - Blood-injection-injury type 1
4. Phobia - Situational type 1
5. Phobia - Other type 3
"Other Phobia" explanation Unwavering hatred of Social Studies and studying about wars even though he has never had to study about wars. He is allergic to shrimp but it has (in his mind) become more extreme to where now he doesn't like to smell them or eat fish that could have been cooked with them. When he eats them he says that they "hurt his throat" but he has never really had a "real" reaction to them ie throat closing up, vomiting, etc.
6. Exposure to fear or phobia causes anxiety, panic attacks, crying, tantrums, or clinging
3 7. The fear or phobia is avoided or else endured with intense anxiety or distress
3 8. Fear or phobial intereres with school, work, friends, or family
3
Selective Mutism
2. Consistently fails to speak in specific social situations 5 1. Not speaking interferes with his or her school, social life, or work
3 3. Not been speaking in social situations for a period of at least one month
1
Pica
1. Eats inappropriate objects (non-nutritive objects) for at least one month
0 2. Eating of non-nutritive items inappropriate for his or her development level
0
3. Eating behavior part of culture 0
Tic Disorders
1. Tics 10
2. Tics occurrence 10
3. Tics vocal 10
4. Tics motor 10
Onset of tics before the age of 18 yes 5. Tics caused by a substance or medical condition? 5
Enuresis
1. Urinates in inappropriate places at least twice a week for 3 consecutive months
2
Encopresis
1. Pass feces in inappropriate places at least once a month for 3 consecutive months
1
Reactive Attachment Disorder
1. Does not warm up or bond to caregiver(s) 2 2. Does not want to be comforted by caregiver(s) 0 3. Does not care who he or she bonds with 1
Reactive Attachment Disorder
4. Too friendly with strangers 6
6. Physical neglect 0
5. Emotional neglect 0
7. Changed primary caregivers often at a young age 3 Distancing from caregiver or friendliness to stranger
behavior before the age of 5
yes
Autism Spectrum Disorder
1. Unable to feel or show the emotions that would be expected by others
6
Explain emotions He has been this way since he was 4 or 5 years old.
2. Deficits in non-verbal communicative behavior 6
Explain deficits in communication He will just stare blankly at someone, as though they can read his mind and know what he wants.
3. Deficits in developing or maintaining relationships 6
Explain deficits in relationships He often times just wants to be alone.
4. Stereotyped or repetitive speech, motor movements or use of objects
6
Explain repetitive speech He will often times repeat a question that he has been asked, without actually ever answering the question.
5. Routines, rituals or excessive resistance to change 3 6. Preoccupation with parts of objects or fixed interest 6
Explain preoccupation He is fascinated by ceiling fans and other moving or rotating objects. He will stare at them for very long periods of time.
7. Unusual interest in sensory aspects of environment 6
Explain unusual sensory apsects He is very sensitive to bright sunlight.
8. Were symptoms present since early childhood 6
Explain presence of symptoms I first began to notice then when he was 4 or 5 years old.
9. Do other people feel the patient is odd 8
Sensory Processing Disorder
1. Sensitive to bright lights 4
Sensory Processing Disorder
2. Difficulty telling the difference between similar printed letters or figures
0 3. Difficulty telling the difference between different colors, shapes, and sizes
0 4. Makes reversals in words or letters when copying, or read words backwards
0 5. Difficulty finding differences in pictures, words, symbols, or objects
0 6. Difficulty with jigsaw puzzles, copying shapes, cutting or tracing lines
3
7. Confuses left and right 0
8. Has difficulty discriminating between sounds and words 3 9. Bothered by loud, sudden, metallic, or high-pitched
sounds
3 10. Difficulty attending to, understanding, and remembering what is said or read
6 11. Looks at others for reassurance before answering a
question
1 12. Prefers playing by him or herself with objects or toys rather than with people
5 13. Does not interact with peers or adults as expected for his or her age
7 14. Others have a hard time interpreting the patient's cues, needs, or emotions
7 15. Does not seek out connections with familiar people 4 16. Difficulty accepting changes in routine 2 17. Participates in repetitive play for hours 2 18. Requires excessive help from caregiver to fall asleep 0 19. Becomes too hot or too cold sooner than others in the same environments
0
Sensory Processing Disorder
20. Respiration and heart rate take longer than what is expected to slow down during or after exertion or fear
0 21. Cannot feel the necessary sensation that bowel or
bladder is full
2
Symptoms present 6 months yes
Dissociative Disorder
1. Inability to recall important personal past information 8 2. Symptoms cause significant distress or impairment at school, work, home, or with friends
7 3. Confused about personal identity or assuming a new
identity (partial or complete)
0 4. Presence of two or more distinct identities or
personalities that take control of behavior
0 5. Experience feeling detached from others or self 1
MILITARY HISTORY
06. Military History
Parents serve in military no
TREATMENT
07. Treatment History
Treatments not currently undergoing therapy, counseling Required emergency or ambulance transportation in the
past 12 months
no Visited the Emergency Room in the past 12 months no
Past medications Orap intunive
Number of previous couseling or therapy sessions more than 6 Was the counseling or therapy helpful yes
08. Current Treatment
Currently taking medication yes
Current Medications CLONIDINE HYDROCHLORIDE :
dosage - 0.1MG frequency - Twice a Day
DEXMETHYLPHENIDATE HYDROCHLORIDE : dosage - 10MG
frequency - Once a Day
FLUOXETINE HYDROCHLORIDE : dosage - EQ 10MG BASE
frequency - Once a Day Current medications not on the list no
Overall effectiveness of current medication(s) very - visible improvement Side effects from current medication(s) no
Currently receiving counseling or therapy yes
Type of counseling or therapy Social skills class
Currently taking OTC medications no
Currently taking vitamins no
Currently taking herbal supplements no
DEVELOPMENT
09. Conception And Pregnancy
Pregnancy planned
Did the mother receive prenatal care yes
During pregnancy the mother was healthy
Did the patient move excessively in the womb no Did the mother use alcohol, illicit drugs or was she exposed to violence during pregnancy
no
10. Birth
Where was the patient born de-identified
Child Birth Process caesarian
Was anesthesia used no
10. Birth
Complications at birth not to my knowledge
Other complications none
Premature birth no
Birth weight known yes
Birth weight 8 lbs. 4 oz.
11. Development
Concerns about childhood development no
Age first slept through the night less than 6 months old
Age toilet trained at age 2 or earlier
Wets the bed yes
Spoke first words before age 1
Currently speech is advanced
Began walking at what age between age 1 and 2
Currently walking is normal
12. Early Temperament
Behaviors exhibited as a baby or toddler other Describe temperament as a baby and toddler easy child
13. Adoption
Is the patient adopted no
PAST MEDICAL HISTORY
14. Past Psychiatric History
Ever been hospitalized for a psychiatric or mental illness no Ever had a workup or been diagnosed with ADHD yes
Ever had a workup or been diagnosed with learning disabilities
Yes. he is thought to have Asperger tendencies and has full blown Tourette's.
Ever had a workup or been diagnosed for sleep disorders no
15. Past Medical History
Suffer from a chronic illness, seizures, convulsions, or fainting
no
15. Past Medical History
Fracture or broken bone no
Tonsillectomy no Appendectomy no Adenoidectomy no Cholecystectomy no Cancer Surgery no Cardiovascular Surgery no Plastic Surgery no Eye Surgery no Other Hospitalizations no
Suffer from diabetes type I or II no
Experienced event that caused head injury or neck whiplash
no
ALLERGIES
16. Allergies
Food allergies yes
Environmental allergies no
Medication or drug allergies no
FAMILY HISTORY
17. Family History
Biological family suffers from diabetes no Biological family suffers from stroke no Biological family suffers from heart disease no Biological family suffers from hypertension or high blood pressure
17. Family History
Attempted or committed suicide no
Obsessive-compulsive behaviors no
Depression no
Schizophrenia no
Behavioral problems no
Legal problems no
Difficulty paying attention yes
Difficulty paying attention experienced by maternal aunt(s), mother
Hyperactivity no
Irritability no
Anger no
Violence/assaultive no
Mood swings no
Anxiety or excessive worries no
Sleep difficulties yes
Sleep difficulties experienced by maternal grandmother Academic or school-related problems yes
Academic or school-related problems experienced by father
Concerned with body weight no
Bizarre behavior no
Hallucinations no
Other family mental health problems none
Other mental or physical family history information that would be helpful
no
SOCIAL HISTORY
18. Support System
Marital status of biological parents divorced
Who has legal custody of the patient biological parent(s) Patient's primary care provider biological mother
Other providers biological father
Has contact with at least one biological parent yes Has contact with the parent that does not live with him or her
18. Support System
Who raised the patient biological mother, biological father Other person who raised the patient. none
Who does the patient feel closest to biological mother What type of home does the patient live in house
How many people live in the patient's house three
Number of times changed residences never moved
Relationship with father figure healthy
Relationship with Mother figure healthy
Siblings yes
Number of siblings One younger sister, age 6
Relationship with siblings healthy
"Other" type of relationship with siblings Typical brother/sister relationship. Sometimes they get along well and sometimes they fight.
Receives primary support from family
Describe family support system Overall very good, as both parents work together. Grandparents step in and help, although paternal grandparents give in to demands and do not back up parent rules, which causes problems. They also undermine guidelines set forth by parents and professionals. The standards in the three houses (mother, father, grandparents) are all different. Expectations are highest at mother's, lower at the father's, almost non-existent at grandparents. This is just my point of view.
Describe other support system none
Religious preference Methodist
19. Safety
Experienced sexual abuse no
Experienced physical abuse no
Experienced emotional abuse no
Experienced neglect by caregivers no
Takes unreasonable risks no
History of violent or aggressive behavior no
20. Stressors
20. Stressors
Identify the other stressors none
21. Education
Currently in school yes
Name of School de-identified
What grade 3
Current academic grade average b or c
Unusually long time to complete homework yes Repeated, failed, or nearly failed a grade no Significant change in current grades yes
Past grade average b
Highest grade level 3
Typically more difficult school subjects as a child reading, social studies Typically easier school subjects as a child math, science, spelling Receive(d) special education services no
Is the patient's Individualized Education Program (IEP) available
no Ever received psychological testing for learning problems no Experienced significant behavioral problems in school yes
21. Education
How many times suspended from school never
22. Leisure
Leisure activities plays video games or computer games, watches tv, other
Frequency playing video games 1-2 days a week
Time spent playing video games 1-2 hours a day
Frequency watching TV 1-2 days a week
Time spent watching TV 3-4 hours a day
Other leisure activities bicycle riding, other
Patient is very good at Spelling, math, visual recognition, interesting observations, asking questions. He wants to be good and do what's right, he wants to make friends, etc.
23. Legal
Ever arrested no
Involved with legal system or charges pending no "Child in need of supervision (CHINS)" petition no
Probation or parole officer no
24. Quality of life
Complies with family rules at home yes
Gets along with peers no
Thinks life has treated him or her fairly no
Level of stress: Family 4
Level of stress: Significant Relationship 3
Level of stress: Health 1
Level of stress: Finances 0
Level of stress: School, if applicable 7 Level of stress: General Well-being 5 Level of stress: Emotional well-being 6 Level of stress: Coping with daily problems 4
Severity Scale
1
2
3
4
5
6
7
Normal
Borderline
Mild
Moderate
Marked
Severe
Extreme
REVIEWED BY CLINICIAN
Severity
Attention-Deficit/Hyperactivity Disorder, Combined Type
Status: Accepted by Clinician
5
Autism Spectrum DIsorder
Status: Accepted by Clinician
5
Overanxious/Generalized Anxiety Disorder
Status: Accepted by Clinician
5
Learning Disorder
Status: Accepted by Clinician
5
Obsessive-Compulsive Disorder
Status: Accepted by Clinician
5
Oppositional Defiant Disorder
Status: Accepted by Clinician
6
Sensory Processing Disorder.
Status: Accepted by Clinician
6
Social Phobia (Social Anxiety Disorder)
Status: Accepted by Clinician
5
Suicide Warning
Status: Accepted by Clinician
2
ADDED BY CLINICIAN
Severity
Tic Disorders
Status: Tic Disorders
5
This report reflects that Deidentified is experiencing difficulty controlling some behaviors because of impulsivity and/or hyperactivity. This youngster most likely makes a lot of careless mistakes in paperwork or schoolwork, has difficulty paying attention, doesn’t listen, is unorganized, and avoids tasks that require attention. This youngster may have a hard time following instructions, loses things frequently, and often is forgetful in daily activities. Persons with similar reports tend to fidget often, run or climb excessively, find it difficult to remain seated, talk excessively, blurt out answers, and interrupt or intrude on others. This youngster may also often appear to be on the go and have difficulty waiting for his or her turn.
Persons with similar reports tend to have difficulty making eye contact, understanding or using gestures, tendency to look and listen less to people in their environment or fail to respond to other people. This youngster may have problems with social communication with others and consequently have difficulty making friends. This youngster may rarely seek to share enjoyment of toys or activities by pointing or showing things to others and may show unusual reponse when others show affection, anger or distress. This youngster may be inflexible, easily fixated on routines, objects or rituals and show behaviors that are very unique or odd.
Deidentified shows a pattern of extreme worry about many things, even when there is little or no reason to worry about them. This youngster may be very anxious about just getting through the day and think that things will, most of the time, go wrong. This youngster may feel restless, keyed up, on edge, easily fatigued, irritable, tense, and have problems sleeping. This youngster may have difficulty concentrating.
Deidentified has a clinical profile that reveals symptoms associated with continuing difficulties in academics during formal years of schooling. This youngster may have symptoms that include incorrect or slow and effortful reading, poor written expression that lacks clarity, difficulties remembering number facts, or inaccurate mathematical reasoning. Current academic skills may be well below the average range of scores. These difficulties probably interfere with academic achievement, occupational performance, or activities of daily living. A developmental, neurological, sensory (vision or hearing), or motor disorders need to be considered as well.
This report suggests that Deidentified is experiencing obsessions that may include contamination, repeated doubts, ordering, aggressive or horrific impulses. This youngster probably tries to neutralize the obsessive anxiety with behaviors that ultimately become compulsions, or an uncontrollable urge to do something repeatedly to neutralize the obsessions . This youngster may try to resist the compulsions, then this youngster has a sense of mounting anxiety that is partially relieved by yielding to the compulsion(s) , sometimes with rituals, otherwise, if this youngster cannot yield, then this youngster may get tense and even very angry, which may frequently result in interpersonal problems with others.
This report indicates that Deidentified is experiencing oppositional and defiant behavior which is grossly out of proportion compared to people the same age. This youngster may be more openly uncooperative and hostile and may be more argumentative, irritable, easily annoyed and have a spiteful attitude.
