36C26118Q0315-011.pdf

Addendum A - SOCIAL WORK PSYCHOSOCIAL ASSESSMENT NOTE

SOCIAL WORK PSYCHOSOCIAL ASSESSMENT

Presenting Problem:

Patient Demographic History:

Age:

Gender:

Marital Status:

Ethnicity:

Branch of Service:

Service Branch Service # Entered Separated Discharge Combat

VA Eligibility:

Emergency Contact:

Name:

Relationship:

Address:

Phone:

Is this your Legal NOK?

(if not, who):

Advance Directives/DPOA:

Please see Advance Directive Note:

Current Living Situation:

Family History:

Relationship Status:

Social Relationships and Peer Group:

Abuse / Neglect History:

Spiritual/Religious/Ethnic/Cultural:

Recreation/Leisure:

General Physical Health:

Current Level of Functioning:

Ambulation:

Bathing:

Toileting:

Dressing:

Feeding:

Shopping:

Cooking:

Household Chores:

Pay Bills:

Transportation:

Required assistive devices (specify):

Is he/she independent when he/she uses these devices?

Can the patient remember his/her appointments?

Can the patient self-administer his/her medications?

Significant Work History:

Educational History/Level:

Financial Information:

Insurance Information:

Legal Issues:

Substance Abuse History:

Mental Health / Psychiatric History:

Mental Status:

Communication Skills:

Patient Strengths:

Social Work Clinical Impression/Assessment:

Social Work Plan, Referrals, Follow-Up Needed:

Patient/Family Agrees with Plan:

(Electronic Signature, Computerized Patient Record System)