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
