i need to make Psychological Assessment Report. i have mentioned the point that i required. you just need to write detailed paragraph on mention headings. all informention is given below. paragraph must be detailed Identifying Information Referral Source and Presenting Problems Interviewing Information Psychological Evaluation Behavior during Sessions Prognosis
i need to make Psychological Assessment Report. i have mentioned the point that i required. you just need to write detailed paragraph on mention headings. all informention is given below. paragraph must be detailed
- Identifying Information
- Referral Source and Presenting Problems
- Interviewing Information
- Psychological Evaluation
- Behavior during Sessions
- Prognosis
Client’s name: Shweta sumit Dhaware gender: Female religion/sect: Hindu Date of birth: 1/3/1996 age: 26 marital status: unmarried
Father’s name: Smit dhaware. age:42
Mothers name: Kalpana Dhaware age: 38
- Presenting Problems ( Nature Of Problems, Precipitating Event, Patient’s Feelings And Thoughts About Problems) Irregular & Painful Menstrual cycle. Heavy blood flow, Floods of blood excreted during periods, black dark areas on thighs & under neck, pimples on face.
- History Of Problems (Duration Of Present Problem, Changes In Nature, And/ Or Frequency Of Problem Over Time, Prodromal Manifestations, Other Past Problems Of A Psychological Nature, No. Of Attacks):-Not got period for 4 months. Last year also diagnosed with same problem. Obesity is also seen in patient.
- Prior Treatment (Details Of Problems Sought For Presenting Problems And For Whom ; When And For What Duration Treatment Undergone; Nature Of Treatment Methods ; Names And Dosages Of Drugs Taken; Ects , Faith Healing Etc; Response To Treatment Including Adverse Reactions And / Or Side Effects):- Took 6 months course treat ment including Taking pills of Pause MF, Muftol spas etc during periods.Injection for heavy periods. After taking these medicine Patient observed enormous weight gain, fatigue, Sleepyness.
4. Medical History ( Most Recent Physical Exam : Date And Results; Current Medications ; Health Condition Since Childhood Including Details Of Serious Illness/Disabilities Suffered And Surgery Undergone ; Eating And Sleeping Habits If Remarkable And Any Change Of Same ; Use Of Stimulants, Alcohol And Drugs):- Regular check up diagnosed blood pressure. Got serious shock during brother's death since last year. Regular eating habits.
5. Family History (Migrations, Births , Marriage, Serious Illness , Deaths , Jobs Of Earning Members , Relationship With Family Members):- Death of small brother in train accident. Father is Government employee.Good Relationship With Family Members.
6. School History( Marks/Divisions Obtained, School Changes, School Problems , Relationships With Peers And Teachers , Extra-Curricular Activities):- Brilliant student always passing with distinction., good Relationships With Peers And Teachers. Playing Basketball, Baseball.
7. History Of Friendships( Nature And Extent Of Friendships, Recreational Activities, Degree Of Religiosity, Sexual History-Premarital, Marital , And Extra Marital Sexual Relationships)-good friend circle of 6-8 members, no affairs.
8.Are you currently employed: ( ) no ( √ ) yes
any work-related stressors, if any _ No
Orientation (Person, Place, Time) -No
Sleep (Insomania, Nightmares)Insomania
Attention ( Concentration, Memory) Good
Thought (Unusual Concept Including Suspiciousness And Delusions, Conceptual Disorganization Including Loosening Of Associations):- Suspiciousness And Delusions
Affect (Crying Spells, Depression, Guilt, Feelings, Suicidal, Excitement, Hostility): Depression
Behavior ( Speech , Mute, Depression, Abusive; Motor: Restless, Assaulting , Destructive, Excited , Motor Retardation):Depression
Mannerisms And Posturing ( Unusual Gestures, Preservative Moments):Unusual Gestures
Anxiety( Tension, Nervousness, Phobias, Obsessions):Tension, Nervousness
Somatoform ( Conversion, Hypochondriasis):No
Psychosexual Problems: :No
Psychosomatic (Obesity, Headaches, Painful Menstruations, Skin Disorders , Asthma, Ulcers, Nausea And Vomiting):-Obesity, Painful Menstruations
Addictions ( Prescribed Or Non-Prescribed Medications, Narcotics Use, Smoking , Pan/Tobacco Chewing, Alcohol Use, Gambling):-Narcotics use, Alcohol use
Family Psychopathology (Nature History And Treatment Of Mental Disorders In Members Of Patient’s Family):-None
Personality Traits (Paranoid, Schizoid, Schizotypal, Antisocial, Borderline, Dependent, Obsessive, Compulsive, Passive, Aggressive) :- Obsessive
Interview Behavior (Open, Secretive, Anxious, Relaxed, Withdrawn, Cooperative, Timid, Compliant, Opposition):- Open, Cooperative, Anxious
Tentative Diagnosis:- PCOD
What do you consider to be your strengths? Confident, Quick learner, leadership qualities.
What are effective coping strategies that you have learned? :- always be positive in any devastating situations
What are your goals for therapy?:- Taking diet plan an exercise plan strictly prohibiting Narcotics & Alcohol use.
Recommendations (Also List Tests):- Ovary Scanning, Sonography of ovary, Thyroid test. Sugar test.
Final Diagnosis :- PCOD ( Polycystic Ovarian syndrome or disease)
Date Of Termination :-Unilateral
Reasons For Termination:- Diagnosed with PCOD
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