Psychosocial Assessment

1. General statements of clients feelings about self.

A. Degree of satisfaction
____________________________________________________________________
B. Clients position in home.
____________________________________________________________________
C. Most significant relationship.
____________________________________________________________________
D. Community Activities.
____________________________________________________________________
E. Family cohesiveness.
____________________________________________________________________
2. Activities.
A. Work
_____________________________________________________________________
B. Hobbies
_____________________________________________________________________
C. Ability to accomplish all that is desired during period (days or week) Why?
_____________________________________________________________________
D. Cultural or religious practices.
_____________________________________________________________________
E. Occupational history.
_________________________________
_________________________________
_________________________________
F. Recent changes in clients life.
_____________________________________________________________________
G. Coping strategies for stressful situation.
_____________________________________________________________________
H. Changes in personality.
A. Behavior
B. Mood
C. Nervousness
D. Feelings of depression
______________________________________________________________________
______________________________________________________________________
I.

Uses of techniques or medication during time of anxiety, stress or depression.

______________________________________________________________________
______________________________________________________________________

J. Habits
Alcohol and Drugs
A. Type of alcohol.
________________________________________________________________
B. Frequency per week.
________________________________________________________________
C. Alcohol/Drugs consumption variances when anxious stressed or depressed.
________________________________________________________________
D. Dangerous activities when under influence.
________________________________________________________________
K. Smoking
A. Kind
_____________________________
B. Amount per day
_____________________________
C. Smoking Variances
_____________________________
D. Desire to quit smoking
_____________________________

L. Coffee and tea

A. Amount per day.
______________________________________________
B. Consumption variances.
______________________________________________
C. Physiologic effects.
______________________________________________
M. Financial status
A. Source of income.
_____________________________________________
B. Adequacy of income.
_____________________________________________
C. Recent changes of resource.
_____________________________________________