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Date:
06/21/2006
Client:
000030 Aldringey Fname Jr
Time:
8:11am
DA ID:
0616200650111
Diagnostic
Assessment - Section II: Mental Status
Clinician:
130 Chrystal Lovelace
Provider:
Pathways
Date:
06/16/2006
Time:
15:20
Physician:
3033 Barney Rubble
Provider:
Bedrock
Date:
06/19/2006
Time:
15:31
Appearance
and Attitude:
Describe
consumer's appearance and attitude:
Well groomed appearance, cooperative but depressed.
Agitated?:
YES
Anxious?:
Restless?:
Depressed?:
YES
Pacing?:
Exhibits odd
behavior?:
Appears
under influence of drugs or alcohol?:
If
consumer answered yes to any of the above and not previsouly described, please explain:
Clt seemed to be getting more and
more agitated while talking, as if she was irritated to have to be here.
Mood and
Affect:
Describe
consumer's mood and affect:
Depressed mood, flat affect.
Depressed?:
YES
Labile?:
Anxious?:
Angry?:
Flattened?:
Euphoric?:
Suspicious?:
If consumer answered yes to any of the above and not
previsouly described, please explain:
Clt seemed very down and
discouraged. She cried a lot.
Thought
Process:
Describe
consumer's thought process:
Organized thought processes.
Articulate?:
Suspicious?:
Organized?:
YES
Flight of ideas?:
Scattered?:
If
consumer answered yes to any of the above and not previsouly described, please explain:
Content
of Talk:
Describe
consumer's content of talk:
Clt spoke mostly about her depression
and caring for her mother
Delusional?:
Suicidal?:
Paranoid?:
Danger to
self?:
Hallucinations?:
Danger to
others?:
Anxious?:
Homicidal?:
Depressed?:
If
consumer answered yes to any of the above and not previsouly described, please explain:
Sensorium:
Oriented
to time, place, situation?:
YES
Describe
consumer's orientation to time, place, situation: