Aaron - Client Update


ECR #  

Client Update

 


Parent's  Name : Todays Date :  

Client's Name :   Date of Birth :  


Brief Mood Survey

Please indicate how you've been feeling over the last 7 Days, including today.

1- Sad or down in the dumps


2- discouraged or hopeless

3- Low self-esteem

4- Worthless or inadequate

5- Loss of pleasure / satisfaction in life
 
Total Items 1-5 : _____


Suicidal Urges


1- Do you have any suicidal thoughts?


2- Would you like to end your life?

Total items 1-2 : _____


Anxiety

1- Anxious

 
2- Frightened
 
3 -  Worrying about things over & over
 
4 - Tense or on edge
 
5 -  Nervous
 
Total items 1-5 :_____


Panic

1 -  Sudden feelings of terror or overwhelming fear.

 
2 -  Sudden, terrifying panic attacks that come out of the blue.
 
3 -  Suddenly feeling you're going crazy or cracking up.
 
4 -  Suddenly feeling you're about to suffocate or pass out.
 
5 -  suddenly feeling you'll have a stroke, heart attack or die.

Total Items 1 - 5 :_____


Anger

1 -  Frustrated

 
2 -  Annoyed
 
3 -  Resentful
 
4 -  Angry
 
5 -  Irriated
 
Total items 1-5 :_____


Impulsivity & concentration

1 - Impulsivity

 
2 -  Difficulty concentrating, careless mistakes
 
3 -  Restless, fidgety, can’t sit still

4 -  Easily bored, trouble finishing things
 
Total items 1-4 :_____


 


Current medication & Reason                                                                            Max Dose                      Dates Taken
 
 
 
 


Review of Systems - please check if you have NEW symptoms or medical problems in the following areas.


 

Do You have physical pain?

IF yes, pain location : 


 

is there anything else that would be helpful for your provider to know?

Leave this empty:

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Signature Certificate
Document name: Aaron - Client Update
lock iconUnique Document ID: 115dd08046eea12bb6d47dfcc36cd5d362d315d9
Timestamp Audit
August 18, 2021 9:31 am PDTAaron - Client Update Uploaded by Adam Falk - adam.falk@options.org IP 206.192.252.48
August 18, 2021 12:45 pm PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48
August 18, 2021 2:27 pm PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48
August 18, 2021 2:29 pm PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48
August 18, 2021 2:31 pm PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48
September 2, 2021 11:39 am PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
September 2, 2021 11:40 am PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
September 2, 2021 11:41 am PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
September 2, 2021 11:47 am PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
September 2, 2021 11:50 am PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
September 2, 2021 11:51 am PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
September 3, 2021 12:42 pm PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48
September 13, 2021 12:58 pm PDTBarbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48