Biopsychosocial Assessment: Part 2

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Brown_PCN-610.R.T2-T3BiopsychosocialAssessment.docx

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Psychosocial Assessment ____ Part 1 (Topic 2)

Template ____ Part 2 (Topic 3)

Name: David____________________ Date: May 8, 2018__________ DOB: N.A.____________

Age: 49________________________ Start Time: 1:30 pm________ End Time: 3:30 pm_________

Identifying Information:

David is a 49-year-old man who has been married 21 years and has two adult children. For 20 years he has been employed as a metallurgical engineer in a local steel mill.

Presenting Problem:

David has been blue for the last 6 months. He states that he has lost his appetite, has been irritable with no energy and has no desire to do anything enjoyable. He admits that he prefers spending time alone in his room. David states that he has been experiencing back and neck pain within the last 2 months. He has not been sleeping well and admits to drinking more alcohol to help him sleep. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Life Stressors:

David is experiencing physical pain in his back and neck area ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Substance Use/Abuse: |X| Yes |_| No

In the past David drank more frequently but now he only drinks two or three beers per night. He drinks more at night to aide in sleep.

Addictions (i.e., gambling, pornography, video gaming)

David is addicted to alcohol consumption. Besides, when he was younger, he used to drink alcohol more frequently than he does currently. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical/Mental Health Hx/Hospitalizations:

David has never been hospitalized but he experiences physical pain in his back and neck area, he is irritable, has low energy, blue and his appetite has decreased. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Abuse/Trauma:

The is no evidence of abuse or trauma.

Social Relationships:

David and his family has meals together as well has attend family gatherings but nothing else. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family Information:

Lisa, David’s sister struggles with depression and has for over 10 years. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Spiritual:

There is no evidence of spirituality. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Suicidal:

David has contemplated suicide on the basis that life is not worth living. ________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

Homicidal:

David has never contemplated killing anyone including his family members despite his mental health condition.

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Assessment:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Initial Diagnosis (DSM):

________________________________________________________________________________________________________________________________________________________________________

Initial Treatment Goals:

Plan:

Name: _____________________________________________ Date: __________________