psych assessment/chemical dependency

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created 6 years ago by erinkcava
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1

general observations

appearance-neat, unkempt, other

grooming-clean, dirty

dress-normal, inappropriate

motor activity-agitated, retarded, catatonic, tremerous

physcial condition-well nourished, emaciated, other

rapport/reaction-comfortable, cooperative, uncooperative, suspicious

2

sensorium

memory-immediate, recent, remote use 3 words

orientation-person, place, time, situation

semantic/Intellectual function-ask 5 questions average-4-5, above-expands on answers, below-less than 3

concentration-intact, not intact-spell WORLD backwords AND perform serial 3/7s, if literacy is a problem have client state the days of the week or the months backwards

Abstraction-use proverbs and similarities, concrete/abstract

calculation-simple mathematics yes/no-how many quarters in 1.50