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Name
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Full Name
Height
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Weight
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B/P
H/R
Temp
During the past four weeks, how much have you been bothered by any of the following problems? Please check any of the below problems in the last four weeks or since your last appointment and give brief description of problem.
Constitutional
Fatigue
Fever
Night Sweats
Restlessness
Description (Constitutional)
Head, Ears, Eyes, Nose, Throat
Headaches
Ringing in ears
Extreme mouth dryness
Mouth sores
Runny nose
Extremely dry nose or soreness in nose
Blurred vision
Sensitivity to light
Description (Head, Ears, Eyes, Nose, Throat)
Neuro
Headaches
Weakness
Seizures
Head Trauma
Numbness
Dizziness
Confusion
Memory loss
Difficulty walking
Tremor
Uncoordinated
Description (Neuro)
CV
Chest pains
Shortness of breath during exercise
Shortness of breath when lying flat
Feeling like your heart is skipping a beat or has an extra beat
Dizziness
Description (CV)
Resp
Shortness of breath
Wheezing
Coughing
Description (Resp)
Gi
Nausea
Gas
Indigestion
Vomiting
Stomach pain
Blood in stool
Constipation
Loose bowels
Diarrhea
Description (Gi)
Gu
Urinary urgency
Urinating more frequently
Painful Urination
Are your pregnant or suspect you may be pregnant
Description (Gu)
Skin
Rash
Itching
Excess Hair Growth
Self Injurious Behavior
Description (Skin)
Endo
Chest tenderness or discharge
Weight gain
Weight loss
Change in libido
Diabetes
Description (Endo)
Lymph
Increased bleeding
Lymph node enlargement
History of blood clotting
Description (Lymph)
Have you thought about or done any of the following:
Destroy property
Hurt animals
Set fire
Listen to music with violent message
Use alcohol
Use drugs
Smoke cigarettes
Sex without protection
Suicide attempt
Description
Please list any changes in your mood or thoughts.
Do you experience any of the following:
Thoughts of suicide
Increasing depression
Anxiety
Auditory or Visual Hallucinations
Paranoid Thinking
Self harm behaviors
Anger
Acting out
Fighting (verbally or physically)
Aggression / scaring others
Sleeping more than usual
Sleeping less than usual
In a few sentences, please provide an update on how you have been doing and any concerns you have about your mood or medication.
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WITH REGARD TO MEDICATION Please rate the degree of change you have noticed from the time you began treatment with Bancroft Behavioral Health. (Please select only ONE).
A very great deal better (+7)
A great deal better (+6)
Quite a bit better (+5)
Moderately better (+4)
Somewhat better (+3)
A little bit better (+2)
A tiny bit better (+1)
A very great deal worse (-7)
A great deal worse (-6)
Quite a bit worse (-5)
Moderately worse (-4)
Somewhat worse (-3)
A little bit worse (-2)
A tiny bit worse (almost the same) (-1)
About the same (0)
Signature
*
Date
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Date Format: MM slash DD slash YYYY
In the event that I am feeling in any way unsafe, unable to predict actions the would jeopardize my safety or the safety of others OR: If I am the parent/guardian of the above named person and believe that they may harm themselves, have harmed themselves, are acting out in ways that jeopardize the safety or themselves OR others - I make pledge and a promise while bering treated by Bradley S why / Bancroft Behavioral Health, that I will talk to the following person:
Name
First
Last
If I am unable to reach this person, I will call 911, I will call Mobile Crisis at: 1-800-652-2929 or I will call the CAPES Unit at Wilmington Hospital: 302-428-2118, Or I will go to the nearest emergency room immediately:
Signature of Parent or Gaurdian
*
Signature of Witness
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