Assessment Report

for

Personality Assessment

Date:

To:

From:

Re:

History and Description of Primary Complaint and Current Related Symptoms

Who Referred

For

Etiology

Symptom Duration

Activity Scale

Assessment Instruments
(examples)

Clinical Interview Minn. Multiphasic Pers. Inventory (MMPI-2)

Beck Depression Inventory (BDI) Zung Depression Inventory (ZDI)

Brief Battery for Health Improvement-2 (BBHI2) Multidimensional Pain Inventory (MPI)

Battery for Health Improvement-2 (BHI2) Beery VMI

Mini-Mental Status Exam (MMSE) Repeatable Battery for Neuropsychological Functioning (RBANS)

Seven Minute Screen for Dementia Substance Abuse Subtle Screen. Inv. (SASSI-3)

Millon Clin. Multiaxial Inven. (MCMI-III) Validity Indicator Profile (VPI)

Dementia Rating Scale-2 (DSR2) Halstead-Raitan Neuropsychological Battery (HRB)

Luria-Nebraska (LNB) Millon Behavioral Medicine Diagnostic (MBMD)

Multidimensional Health Locus Wechsler Adult Intelligence Scale

Of Control Wechsler Intelligence Scale for Children

Presentation

Orientation?

Affect?

Appearance? Dress _____ Hygiene _____

Speech

Memory/cognitive deficit

Psychosis:______Thought disorder_________Uncontrolled mood disorder.

Previous Medical Treatment for Complaint

Physicians

Procedures

Medications

Life Disruption From Present Symptoms

Work

Family

Avocational

Sleep

Appetitie

Commonly Used Coping Mechanisms

Physical pain and discomfort

Affective discomfort and suffering

Any Possible Secondary Gain Issues?

Litigation

Workman’s Compensation

Disability

Addiction Potential

Does this patient drink – How much/frequently? Any legal (DUI) or social (fights with family) about drinking? Does the client use illicit drugs? How much/frequently? What prescription meds? Ever felt “out of control” on the meds? Ever run out of controlled meds early? Has a doctor ever decided not to refill meds

General Medical History

Conditions
–

Medication
–

Allergies
–

Family Medical and Pain History

Current Living Environment

Who does the client life with? What is the circumstance of the home environment.

Life History

Childhood

Reared where?

Parents

Siblings

Discpline

Abuse

Education

Adult

Leaving Home

Marriage(s)

Domestic Abuse

Parental Discipline

Friends

Work History –

Where and for how long? What does the client do at this job?

Avocational Activities –

Hobbies?

Previous Psychological Testing and Treatment —

Expectation for Treatment Outcome

Diagnosis –

Summary and Recommendation

Summary of evaluative instruments

—

Recommendation —