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Aaron - Client Update

ECR #

Client Update

Parent's Name : Todays Date :

Client's Name : Date of Birth :

Brief Mood Survey

Please indicate how you've been feeling over the last 7 Days, including today.

1- Sad or down in the dumps

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

2- discouraged or hopeless

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

3- Low self-esteem

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

4- Worthless or inadequate

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

5- Loss of pleasure / satisfaction in life

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

Total Items 1-5 : _____

Suicidal Urges

1- Do you have any suicidal thoughts?

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

2- Would you like to end your life?

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

Total items 1-2 : _____

Anxiety

1- Anxious

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

2- Frightened

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

3 - Worrying about things over & over

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

4 - Tense or on edge

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

5 - Nervous

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

Total items 1-5 :_____

Panic

1 - Sudden feelings of terror or overwhelming fear.

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

2 - Sudden, terrifying panic attacks that come out of the blue.

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

3 - Suddenly feeling you're going crazy or cracking up.

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

4 - Suddenly feeling you're about to suffocate or pass out.

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

5 - suddenly feeling you'll have a stroke, heart attack or die.

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

Total Items 1 - 5 :_____

Anger

1 - Frustrated

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

2 - Annoyed

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

3 - Resentful

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

4 - Angry

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

5 - Irriated

0 - Not at all

1 - Somewhat

2 - Moderate

3 - A Lot

4 - Extremely

Total items 1-5 :_____

Impulsivity & concentration

1 - Impulsivity Not at allSomewhatModerateA LotExtremely

2 - Difficulty concentrating, careless mistakes Not at allSomewhatModerateA LotExtremely

3 - Restless, fidgety, can’t sit still Not at allSomewhatModerateA LotExtremely

4 - Easily bored, trouble finishing things Not at allSomewhatModerateA LotExtremely

Total items 1-4 :_____

Current medication & Reason Max Dose Dates Taken

Review of Systems - please check if you have NEW symptoms or medical problems in the following areas.

None Weight loss Weight gain Insomnia Chronic Fatigue

Loss of Hearing Seasonal Allergies Sinus Pain ringing in Ears

Chest Pain Hypertension Edema Palpitations High Cholesterol

Asthma Wheezing Frequent Cough

Heartburn / indigestion Ulcer Abdominal Pain Stomach Bleed constipation diarrhea

Arthritis Muscle Weakness Joint Pain Back Pain

Rash Ulcers Scars

Headaches Seizures Numbness Dizziness Problem Walking

None Depression Mood Swings Anxiety

None Diabetes Hyperthyroid Hot Flashes

Easy Bruising Bleeding Heat or Cold Intolerance Anemia Other

Do You have physical pain?

Yes

IF yes, pain location :

is there anything else that would be helpful for your provider to know?

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

August 18, 2021 9:31 am PDT

Aaron - Client Update Uploaded by Adam Falk - adam.falk@options.org IP 100.42.162.250

August 18, 2021 12:45 pm PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

August 18, 2021 2:27 pm PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

August 18, 2021 2:29 pm PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

August 18, 2021 2:31 pm PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

September 2, 2021 11:39 am PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

September 2, 2021 11:40 am PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

September 2, 2021 11:41 am PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

September 2, 2021 11:47 am PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

September 2, 2021 11:50 am PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

September 2, 2021 11:51 am PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195

September 3, 2021 12:42 pm PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48

September 13, 2021 12:58 pm PDT

Barbara Patino - barbara.patino@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 206.192.252.48