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Date: 06/21/2006 Client: 000030 Aldringey Fname Jr Time: 8:11am
DA ID: 0616200650111
Diagnostic Assessment - Section I: Reason for Service
            

Clinician:

 130 Chrystal Lovelace

Provider:

Pathways

Date:

 06/16/2006

Time:

 15:16

Physician:

 3033 Barney Rubble

Provider:

 Bedrock

Date:

 06/19/2006

Time:

 15:31
                                                              
Why are you here today? In consumer's own words, describe presenting problems, symptoms, precipitating events, source of distress, onset and duration.                             
Depression - worse over the past few months.  Numerous situational stressors.  Death of father, clt cared for father through hospice before he died.   Family made clt promise to care for mother.
                            
Current psychotropic medications (including recommended dosages):
Zyprexa 5 mg one tab at bedtime.
                         
History of previous psychiatric treatments including hospitalizations and psychotropic medications:
Clt has never been hospitalized but was on Zoloft about a year ago.
                      
Has previous treatment benefited you?:                          YES
                  
Response to previous treatements:
The Zoloft worked well but clt thought she could handle life without it and stopped taking meds.
   
Family history of mental health issues?:                          YES
    
Description of family history of mental health issues:
Grandmother was diagnosed with Bipolar Disorder and a cousin is manic-depressive.
                   
Section I Addendum:
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