Name
Sujit
Identifying Data
Gender
male
Identifying Data
Work or academic pressure?
no
Risk assessment/Screening ›
Psychosocial Stressors
Financial stress?
yes
Risk assessment/Screening ›
Psychosocial Stressors
Relationship or marital problems?
yes
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?
yes
Risk assessment/Screening ›
Family History
Stress management?
Relaxation / Meditation
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Coping style adaptive vs maladaptive?
Rarely
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Leisure activities?
Never
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Supportive family?
yes
Risk assessment/Screening ›
Protective Factors
Positive peer group?
no
Risk assessment/Screening ›
Protective Factors
Religion or spirituality?
Moderately important
Risk assessment/Screening ›
Protective Factors
Healthy coping strategies?
Never
Risk assessment/Screening ›
Protective Factors
Trauma or abuse?
Yes
Risk assessment/Screening ›
Personal & Psychiatric History
Depression, anxiety?
Yes, both
Risk assessment/Screening ›
Personal & Psychiatric History
ADHD or other disorders?
Yes, ADHD
Risk assessment/Screening ›
Personal & Psychiatric History
Previous psychiatric treatment?
No
Risk assessment/Screening ›
Personal & Psychiatric History
Insomnia?
yes
Risk assessment/Screening ›
Sleep & Daily Functioning
Irregular sleep?
yes
Risk assessment/Screening ›
Sleep & Daily Functioning
Daytime fatigue?
no
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?
yes
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Novelty seeking?
Sometimes
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Poor decision-making?
yes
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Aggression or risk-taking?
Yes-Aggression
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Medical illnesses
Yes- Ongoing
Past History
Psychiatric illnesses
Yes- Past
Past History
Past substance use
Yes- Ongoing
Past History
Substance use in family
yes
Family History
Psychiatric illnesses in family
yes
Family History
Family environment
Supportive
Family History
Birth and developmental history
Minor delays (speech, motor, learning)
Personal History
Childhood adjustment
Minor difficulties (occasional challenges, but managed)
Personal History
Education history
Minor difficulties (occasional struggles, but completed education)
Personal History
Occupational history
Employed, some difficulties
Personal History
Marital and sexual history
Married / cohabiting, some difficulties
Personal History
Social relationships
Supportive and positive
Personal History
Forensic or legal history
Moderate legal issues (e.g., arrests, short-term detentions)
Personal History
Leisure and coping
Regular leisure activities, healthy coping
Personal History
Traits
Generally impulsive or risk-taking
Premorbid personality
Interpersonal relations
Mixed – supportive with some difficulties
Premorbid personality
Hobbies
No hobbies or interests
Premorbid personality
Appearance and behavior
Well-groomed, appropriate behavior
Mental status Examination
Speech
Rapid or pressured
Mental status Examination
Mood and affect
Elevated / unusually cheerful
Mental status Examination
Thought
Rapid or racing thoughts
Mental status Examination
Perception
Illusions (misinterpreting real objects/sounds)
Mental status Examination
Cognition
Alert, attentive, and oriented
Mental status Examination
Insight
Partial insight (some awareness, but minimizes difficulties)
Mental status Examination
Judgment
Moderately impaired (frequent poor decisions)
Mental status Examination
Recently reduced or stopped
No – Still using at same level
Withdrawal Questions
Onset of symptoms
Yes, symptoms started after 1–3 days
Withdrawal Questions
Severity 1 to 10
5–6: Moderate, noticeable and uncomfortable
Withdrawal Questions
Time of day pattern
Continuous throughout the 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
No, never
Withdrawal Questions