Sunrise Health Clinic
123 Wellness Way
Springfield, SP 12345
Date of Exam: 11/01/2024
Time of Exam: 10:30:00 AM
Patient Name: John Doe
Patient Number: 987654321
Biopsychosocial Assessment
History:
John Doe is a 45-year-old male, Caucasian, married, and a resident of Springfield. He states, "I feel overwhelmed and anxious all the time." The information on his anxiety was provided by both the patient and his wife.
Symptoms of Anxiety:
John reports that his anxiety began gradually over the past year, with symptoms occurring almost daily. He experiences excessive worry, difficulty concentrating, and occasional panic attacks.
Current Symptoms:
John describes feeling restless, having a racing heart, and experiencing muscle tension. He states, "I can't seem to relax, and my mind is always racing."
Suicidality: John denies any suicidal ideation or intent.
Anxiety Symptoms: John reports excessive worry, panic attacks, and difficulty concentrating.
Substance Use: John denies any current or past substance use issues.
ADHD Symptoms: John denies symptoms associated with attention deficit disorders.
History of Trauma/Abuse: John denies any history of sexual, physical, or emotional abuse.
Past Psychiatric History:
John has no known past psychiatric history.
Social/Developmental History:
John grew up in a supportive family environment and identifies as Christian. He has two children, ages 10 and 12, who are dependent.
Activities of Daily Living:
John maintains a regular work schedule as an accountant but struggles with work-life balance.
Leisure Activities:
John enjoys reading and playing tennis but has reduced participation due to anxiety.
Barriers to Treatment:
John cites financial constraints and stigma as barriers to seeking treatment.
Client’s Goals:
"I want to manage my anxiety better and feel more in control of my life."
Coping Strengths:
Family Support: John has a supportive wife and extended family who provide emotional support.
Financial Stability: John is financially stable but concerned about future expenses.
Housing Status: John lives in a safe, comfortable home.
Strengths/Assets: John is motivated, resilient, and in good physical health.
Family History:
John's father has a history of depression, and his mother has hypertension.
Medical History:
John has a history of hypertension, managed with medication.
Exam:
John appeared well-groomed, with coherent speech and a cooperative demeanor. His mood was anxious, and his affect was congruent with his mood.
Mood/Affect: John exhibits signs of anxiety but no depression.
Speech: Speech is normal in rate and tone.
Thought Content: Logical thought processes with no delusions or obsessions.
Suicidal Ideation: John denies suicidal thoughts.
Insight & Judgment: John demonstrates good insight and judgment.
Signs of Anxiety: Observable restlessness and occasional trembling.
Attention Span & Eye Contact: John maintains good eye contact and shows no signs of distractibility.
Instructions / Recommendations / Plan:
John is recommended for outpatient treatment with a focus on cognitive behavioral therapy. Follow-up is advised in two weeks, with instructions to contact the clinic if symptoms worsen.
Recommended Treatment Setting: Outpatient treatment.
Therapeutic Approach: Cognitive behavioral therapy.
Follow-up Plan: Return for a follow-up appointment in two weeks.
Notes & Risk Factors:
John is experiencing stress due to work demands and financial concerns.
Billing Code: 90791 Bio-Psychosocial Initial Assessment
Time spent face to face with patient and/or family and coordination of care: 10:30 AM - 11:30 AM
Clinician Name & Credentials: Nurse Jane Smith, RN
Electronically Signed
By: Nurse Jane Smith, RN
On: 11/01/2024 11:45 AM
