Name
Surjit
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?
yes
Risk assessment/Screening ›
Family History
Family conflict or instability?
no
Risk assessment/Screening ›
Family History
Stress management?
Exercise
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Coping style adaptive vs maladaptive?
Never
Risk assessment/Screening ›
Risk Behaviors & Coping Skills
Leisure activities?
Sometimes
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?
Very 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?
Yes – other (please specify)
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?
yes
Risk assessment/Screening ›
Social & Environmental Factors
Community/cultural norms?
no
Risk assessment/Screening ›
Social & Environmental Factors
Exposure to substance use?
yes
Risk assessment/Screening ›
Social & Environmental Factors
Impulsivity?
yes
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Novelty seeking?
Never
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Poor decision-making?
yes
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Aggression or risk-taking?
Yes-Risk-Taking
Risk assessment/Screening ›
Cognitive & Behavioral Patterns
Medical illnesses
Yes- Past
Past History
Psychiatric illnesses
Yes- Past
Past History
Past substance use
Yes- Past
Past History
Substance use in family
yes
Family History
Psychiatric illnesses in family
no
Family History
Family environment
Conflictual
Family History
Birth and developmental history
Normal birth and development
Personal History
Childhood adjustment
Minor difficulties (occasional challenges, but managed)
Personal History
Education history
Completed education without difficulties
Personal History
Occupational history
Employed, some difficulties
Personal History
Marital and sexual history
Single, sexually active
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
Some leisure activities, occasional healthy coping
Personal History
Traits
Generally introverted / reserved
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
Normal perception, no unusual experiences
Mental status Examination
Cognition
Alert, attentive, and oriented
Mental status Examination
Insight
Poor insight (limited awareness, denies problems)
Mental status Examination
Judgment
Mildly impaired (occasional poor decisions)
Mental status Examination
Recently reduced or stopped
Yes – Gradually reduced
Withdrawal Questions
Onset of symptoms
Yes, symptoms started within a day
Withdrawal Questions
Severity 1 to 10
3–4: Mild, manageable without much discomfort
Withdrawal Questions
Time of day pattern
Continuous throughout the day
Withdrawal Questions
Interference with daily life
Very severe / disabling (unable to perform normal activities)
Withdrawal Questions
Cravings to relieve symptoms
Moderate cravings (frequent, sometimes difficult to resist)
Withdrawal Questions
Ever needed medical help
Prefer not to answer
Withdrawal Questions