Initial Evaluation

Initial Evaluation Worksheet

Date:

Claimant:

CASE SUMMARY:

Place of interview:

Date of Interview:

Individuals present:

Medical diagnosis, status, or reason for case management intervention:

INTRODUCTION:

Sex:

Race:

Age and Date of birth:

Height:

Weight (prior and current if relevant):

Physical appearance (pale, weak, etc):

Sensorium (alert, confused, cooperative, etc):

Signed authorization? (if not, state reason):

MEDICAL:

Recent medical history

Recap of events for this illness only (events leading to point we are at now):

Previous medical care

Prior medical-surgical history, including diagnosis, medications, dates, physicians, outcome:

Current medical status and treatment

Current treatment plan, review of medical record (if indicated):

(What is actually being done medically for claimant at this time, related to current diagnosis):

If appropriate, complete a body system review:

Neurological

Gastrointestinal

Cardiovascular

Urological

Dermatological

Respiratory

Psychosocial

Orthopedic

Endocrine

Physician Consultation

(Summarize the physician-case manager personal meeting or telephone consultation):

Date of contact:

Pertinent Data:

Physical plan of care:

SOCIOENVIRONMENTAL

Family makeup and friend support:

What is family’s apparent understanding and feeling regarding illness and treatment?

Religion notes:

Cultural and language notes:

Description of home and neighborhood:

VOCATIONAL

Occupation:

Education:

Impact of illness on work status:

MOTIVATIONAL_BEHAVIORAL

Claimant’s apparent behavior:

Understanding and acceptance of current problem:

Claimant statement regarding compliance:

Subjective emotional adjustment data:

Psychological issues:

Substance abuse issues:

FINANCIAL

Apparent financial difficulties:

Retired or active employee:

Medicare eligible:

Disability:

Worker’s compensation:

Multiple insurance policies:

SUMMARY AND IMPRESSIONS

State concerns, positive aspects, and case management goals

RECOMMENDATIONS:

1.

2.

3.

4.

5.