Name
Mukesh
Identifying Data
Gender
male
Identifying Data
Work or academic pressure?
yes
Risk assessment/Screening ›
Psychosocial Stressors
Financial stress?
yes
Risk assessment/Screening ›
Psychosocial Stressors
Relationship or marital problems?
no
Risk assessment/Screening ›
Psychosocial Stressors
Major life changes?
no
Risk assessment/Screening ›
Psychosocial Stressors
Substance use in family?
yes
Risk assessment/Screening ›
Family History
Psychiatric illness in family?
no
Risk assessment/Screening ›
Family History
Family conflict or instability?
no
Risk assessment/Screening ›
Family History
Stress management?
Relaxation / Meditation
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Coping style adaptive vs maladaptive?
Sometimes
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Leisure activities?
Often
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Supportive family?
yes
Risk assessment/Screening ›
Protective Factors
Positive peer group?
yes
Risk assessment/Screening ›
Protective Factors
Religion or spirituality?
Very important
Risk assessment/Screening ›
Protective Factors
Healthy coping strategies?
Sometimes
Risk assessment/Screening ›
Protective Factors
Trauma or abuse?
No
Risk assessment/Screening ›
Personal & Psychiatric History
Depression, anxiety?
Yes, both
Risk assessment/Screening ›
Personal & Psychiatric History
ADHD or other disorders?
No history of ADHD or other psychiatric disorders
Risk assessment/Screening ›
Personal & Psychiatric History
Previous psychiatric treatment?
Yes – medication treatment
Risk assessment/Screening ›
Personal & Psychiatric History
Insomnia?
no
Risk assessment/Screening ›
Sleep & Daily Functioning
Irregular sleep?
yes
Risk assessment/Screening ›
Sleep & Daily Functioning
Daytime fatigue?
yes
Risk assessment/Screening ›
Sleep & Daily Functioning
Effect on daily functioning?
yes
Risk assessment/Screening ›
Sleep & Daily Functioning
Peer pressure?
no
Risk assessment/Screening ›
Social & Environmental Factors
Community/cultural norms?
yes
Risk assessment/Screening ›
Social & Environmental Factors
Exposure to substance use?
no
Risk assessment/Screening ›
Social & Environmental Factors
Impulsivity?
no
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Novelty seeking?
Often
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Poor decision-making?
yes
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Aggression or risk-taking?
Yes-Both
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Medical illnesses
No
Past History
Psychiatric illnesses
No
Past History
Past substance use
No
Past History
Substance use in family
no
Family History
Psychiatric illnesses in family
yes
Family History
Family environment
Supportive
Family History
Birth and developmental history
Normal birth and development
Personal History
Childhood adjustment
Well-adjusted (generally positive childhood)
Personal History
Education history
Completed education without difficulties
Personal History
Occupational history
Unemployed / student / homemaker
Personal History
Marital and sexual history
Married / cohabiting, stable relationship
Personal History
Social relationships
Supportive and positive
Personal History
Forensic or legal history
No legal issues
Personal History
Leisure and coping
Regular leisure activities, healthy coping
Personal History
Traits
Generally impulsive or risk-taking
Premorbid personality
Interpersonal relations
Mostly positive, occasional conflicts
Premorbid personality
Hobbies
Few hobbies/interests, minimal engagement
Premorbid personality
Appearance and behavior
Well-groomed, appropriate behavior
Mental status Examination
Speech
Normal rate, tone, and flow
Mental status Examination
Mood and affect
Mildly low / anxious
Mental status Examination
Thought
Logical, coherent, and goal-directed
Mental status Examination
Perception
Illusions (misinterpreting real objects/sounds)
Mental status Examination
Cognition
Mild difficulties with attention or memory
Mental status Examination
Insight
Good insight (aware and acknowledges difficulties)
Mental status Examination
Judgment
Intact (makes sound, appropriate decisions)
Mental status Examination
Recently reduced or stopped
Yes – Gradually reduced
Withdrawal Questions
Onset of symptoms
Yes, symptoms started after 1–3 days
Withdrawal Questions
Severity 1 to 10
7–8: Severe, difficult to manage
Withdrawal Questions
Time of day pattern
Only once a day
Withdrawal Questions
Interference with daily life
None / no interference
Withdrawal Questions
Cravings to relieve symptoms
Mild cravings (occasional, manageable)
Withdrawal Questions
Ever needed medical help
Prefer not to answer
Withdrawal Questions