Child and Adolescent Diagnostic Assessment Worksheet

Child and Adolescent Diagnostic Assessment Worksheet
IDENTIFYING INFORMATION: (age, gender, and ethnicity of client; parents)

COLLATORAL INFORMANTS:

CHIEF COMPLAINT: (in the client’s own words)

Other informants:

HISTORY OF PRESENT ILLNESS: (this should create the timeline and details of the child/adolescent symptoms so that it leads to the clinical assessment and formulation) ­­­­­­­­­­­­

PAST PSYCHIATRIC HISTORY/PREVIOUS PSYCHIATRIC VISITS/HOSPITALIZATIONS:­­­­­­­­­­

PAST MEDICAL HISTORY:

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PAST SURGICAL HISTORY:

CURRENT MEDICATIONS (INCLUDING COMPLIANCE):

ALLERGIES:

PSYCHOSOCIAL HISTORY: (who the child lives with, relevant cultural information, school, grade, teacher, friends)

Sexual Orientation/Gender Identity (if unknown, evidence of gender dysphoria):

­­­­­­­­­­­­­­­­­­(NOTE: If LGBT, elicit “out” status, family dynamics): _________________________________

History of physical/emotional/sexual abuse: __________ History of bullying: _________Religion: ________

FAMILY HISTORY OF PSYCHIATRIC ILLNESS:

History of Family Suicide Attempts/Completed Suicides:

SUBSTANCE ABUSE HISTORY:

Smoker: _____History of alcohol, marijuana, meth use/abuse: ____________________________________

REVIEW OF SYMPTOMS:

GENERAL WELL BEING:

(Example:

-Child/parent reports that (she/he) is sleeping (well, poorly, fair). States that (she/he) has trouble (falling asleep, staying asleep, or waking up feeling as if she/he had not slept at all). Child and Adolescent Diagnostic Assessment Worksheet.

-Further, reports (low, fair, good) energy throughout the day.

-Child/parent acknowledges (poor, fair, good) appetite (if fair/poor, indicate how long this has persisted for). Any significant weight loss/gain.

MENTAL STATUS EXAMINATION: (see Kaplan & Sadock’s Synopsis of Psychiatry: Behavior Sciences/Clinical Psychiatry for Child MSE)

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CLINICAL FORMULATION: (Discuss diagnostic reasoning here.) ­­­­­­­­­­­­­­­­­­­­­­

DIAGNOSIS USING DSM-5:

(Begin with psychiatric diagnosis that the patient is being treated for; then, in order of relevance/importance/significance to the overall clinical picture, list the diagnoses. DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. Other conditions that are a focus of the current visit or help to explain the need for a treatment or test may also be coded.) Child and Adolescent Diagnostic Assessment Worksheet.

DIAGNOSIS:

USW1_NURS_6660_week01_childAdolescentDiagnosticAssessmentWorksheet

PLAN OF TREATMENT:

Child and Adolescent Diagnostic Assessment Worksheet

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