Initial Evaluation Template - Magellan Provider

Transcription

Initial Evaluation TemplateDemographic Information(Please complete all questions on this form)Member Name:Date:Name:Address:Phone (Home): Phone (Work):Date of Birth:Social Security #:Guardianship (for children and adults when applicable):Marital Status (check one):[] Never Married[] Divorced[] Married[] Separated[] Widowed[] CohabitingGender:[] MaleAge:Race (optional):[] White[] African-American[] Hispanic[] Native American[] Asian[] Other[] FemaleFamily Members:NameAgeGenderRelationshipEmployer: Occupation:School (for children, and adults when applicable):Referral Source:Insurance Information:Insurance Company/HMO: Phone:Member ID#: Managed Care Company:Claims Address: Phone:Emergency Information:Primary Care Physician: Phone:Name of Emergency Contact: Phone:Relationship to Patient:Source of Information: (patient, family, other): 2017 Magellan Health, Inc. rev. 11/17Page 1

Initial Evaluation TemplatePresenting Problem (include onset, duration, and intensity):Precipitating Event (why treatment now):Mental Status (circle appropriate entation:Mood:Thought Content:Thought pulse ppropriateDisheveledUncleanBizarreInappropriate (describe):(sad, angry, anxious, superficial, restricted, labile, flat)Disoriented to person, place, time, date, day, situationOther(euthymic, depressed, irritable, ressuredLoudExcessiveSlowOtherAboveBelowPartially Present teImpairedImpairedInappropriate (anxious, agitated, guarded, hostile, drowsy,cooperative, hyperactive, psychomotor retarded)Thought Disorder: No ProblemDelusionsIdeas of ialConfusionFlight of IdeasBrain InjuryParanoiaLoose AssociationsThought BlockingHallucinationsPhobiasPrevious Medical History:Allergies (adverse reactions to medications/food/etc.):PCP Name and Telephone Number:Date of Last Physical Exam:Findings from Exam:Any relevant medical conditions (diabetes, hypertension, head traumas, cardiac problems,asthma or other breathing problems, cancer, etc.): 2017 Magellan Health, Inc. rev. 11/17Page 2

Initial Evaluation TemplateFamily Medical History:Current Medications (Include prescribed dosages, dates of initial prescription and refills, andname of doctor prescribing medication):Hospitalizations/Surgeries (include dates, complications, adverse reactions to anesthesia,outcomes, etc.):Past Psychiatric History (Mental Health and Chemical Dependency):Hospitalizations:Family History of Suicide/Homicide: YesNoPrior Outpatient Therapy:Previous practitioners and dates of treatment:Previous treatment interventions:Response to treatment interventions including medications:Results of recent lab tests and consultation reports:Family Mental Health or Chemical Dependency History:Psychosocial Information:Support Systems:School/Work Life:Marital History:Legal History:Military History:Spiritual Beliefs: 2017 Magellan Health, Inc. rev. 11/17Page 3

Initial Evaluation TemplateRisk omicidalIdeationSubstance Abuse History (complete for all patients age 12 and over)AmountFrequencyDurationFirst UseLast hildren and Adolescents Only:Developmental History (developmental milestones met early, late, normal):Peri-natal History (details of pregnancy/labor/delivery):Pre-natal History (medical problems during pregnancy, mother’s use of medications):Risk Factors to include:Non-compliance with treatmentAMA/elopement potentialPrior behavioral health inpatient admissionsHistory of multiple behavioral diagnosisSuicidal/homicidal ideationDomestic ViolenceChild AbuseSexual AbuseEating DisorderOther (describe)Strengths: 2017 Magellan Health, Inc. rev. 11/17Page 4

Initial Evaluation TemplateBarriers:Diagnostic Impression:Axis I/ICD-10:Axis III:Medication Education (as appropriate): Yes N/A Patient Verbalizes UnderstandingDiagnosis Education (as appropriate): Yes N/A Patient Verbalizes UnderstandingFollow-up Appointment:Clinician Signature: Date: 2017 Magellan Health, Inc. rev. 11/17Page 5

Initial Evaluation Template 2017 Magellan Health, Inc. rev. 11/17 Page 4 Risk Assessment Ideations None Noted Thoughts Only Plan (describe) Intent (describe) Means (describe) Attempt (describe) History (Ideation and/or Attempts) Suicidal Ideation Homicidal Ideation Substance Abuse History (complete for all patients age 12 and over)File Size: 489KBPage Count: 5