Biopsychosocial Assessment Criteria Flashcards
What is the presenting problem?
The presenting problem is why they came to see you.
What should be included in the history of the presenting problem?
Include any stressors that contribute to the presenting problem, what they have tried in the past, and how symptoms have progressed.
What developmental aspects should be noted?
Include any developmental delays, milestones, learning disabilities.
What medical history should be documented?
Include present and past medical conditions, medications, dosage, purpose, prescribing physician, and allergies.
What current health status information should be included?
Information about current health status (good, fair, poor), diet, nicotine and caffeine use, and exercise.
What should be included in the mental health history?
Present and past symptoms, medications, suicidal ideation, suicidal attempts, self-harm, and history of trauma.
What types of trauma should be documented in the mental health history?
Include sexual abuse, verbal abuse, physical abuse.
What social history information should be gathered?
Information on social support, friends, family, and the nature of those relationships.
Education and employment history.
What educational history should be included?
Include if they graduated high school, the year, reasons for not graduating, and any college or trade schools attended.
What employment history should be documented?
Include past and current employment and satisfaction with employment.
What legal involvement information should be noted?
Include legal issues, probation, current and past arrests, outcomes, convictions, and any bankruptcy or lawsuits.
What military history should be included?
Include whether they have been in the military, duration, current status, type of discharge, and if they receive Veterans Benefits.
What substance abuse history should be documented?
Include information on substances abused, age of first use, date of last use, method of use, relapses, and recovery status.
What additional information on substance abuse should be included?
Caffeine and nicotine use history.
What should be noted about the history of treatments in Substance Abuse History?
Did they complete treatments, when and where, and for what length of time.
