MENTAL HEALTH ASSESSMENT AND PLAN Patient Details: Name: _____________________________________________ DOB: ___________________ Gender: Female / Male Medical History: Medications: Social History: Occupation: Marital status: Single / Married / Defacto / Divorced / Widowed / Other ____________ Sexual Orientation: Heterosexual / Homosexual / _________________ Lives with: Is a Carer: No Has a Carer: Self Alcohol: Non Drinker / Social Light Drinker / _______________________ Smoking: Non Smoker / Ex smoker / _______________ PART 1- MENTAL HEALTH ASSESSMENT Reasons for Preparation of Mental Health Plan: Outcome Measurement Tool: Tool : K10 Result: Other issues: Previous Mental Health or other behavioural Diagnosis: Substance Abuse History: RISK ASSESSMENT: Thoughts of self harm? Occasional / Regularly / Has a Plan / Other _______________
Presents for a refill of her oral contraceptive pill script Has been on this medication for some time without any ill effect No history of - Hypertension - DVT / PE - Migraine with aura Preventiative health screen: Cervical smears up to date Good Diet Exercises regularly Non smoker No concerns about mood Examination: BP: Reason for contact: Oral contraceptive pill script Management: Script as requested
Patient complains of severe joint pain Joint/s affected: Patient states they have a history of gout and this feels like that On Examination: The patient is afebrile Joint affected feel hot and very sensitive to movement Clinical Impression : Gout Plan: 1. Anti-inflammatory medication prescribed (indomethicin, Colchicine or Prednisone) 2. Apply hot compresses or ice to the joint involved 3. Bed Rest Discussed the usefulness of Allopurinol. Not prescribed at this time but if continued attacks the patient will represent for treatment Discussed the "Rules of Moderation" and these notes have been printed and provided to the patient Rules of moderation Do: • restrict intake of food high in purines, especially organ meats (liver, brain, kidneys, sweetbread), shellfish and tinned fish (sardines, anchovies, herrings), game, pork • reduce your intake of alcohol, especially beer and red wine • reduce or cease intake of sugary, fizzy soft drinks and frui
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