Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
Date of Interview:
INTERVIEWER/S
Time of Interview
Others present
Referrer:
G.P
Legal Status:
Responsible Clinician:
Enduring Power of Attorney:
EPoA on file: yes no
INTRODUCTION
Reason for referral
Consumer’s
reaction to referral
PRESENTING
PROBLEMS
AND HISTORY
Consumer’s belief
of what is wrong.
Why Now?
SYMPTOM
ENQUIRY
Any of the following
not detailed above
Depression
Elation
Anxiety
Panic
Phobia
Obsessions
Compulsions
Version: 6 : Issue date: January 2017
Page 1 of 7
FORM MHS CAF-A
Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
Delusions
Hallucinations
Passivity
experiences
Suicidal/homicidal
ideas & plans
Physical symptoms
related to mental
disorder
SUBSTANCE
Are you Smokefree?
Yes
NRT offered?
Accepted
(see
USE
treatment
plan)
No
Declined
Primary
Substance
of Concern:
(Current or most
recent use, first
use,)
Drugs used (specify type)
Age first
Years of
Approx.
Frequency
Quantity
Method
used
heaviest use
date
of use
Ie. Inject,
last used
smoke,
snort
Alcohol
Cannabis
Synthetic Cannabis
Amphetamines (speed)
Methampethamine (‘P’)
Party Pil s
Ecstasy
Cocaine
Benzodiazepine
Heroin
Methadone - non-prescribed
Methadone – prescribed
Other opioids
Hal ucinogens (LSD, mushrooms)
Solvents / Inhalants
Other
Caffeine
Gambling: Do you gamble?
Yes
No
If yes, is this a problem for you?
Version: 6 : Issue date: January 2017
Page 2 of 7
FORM MHS CAF-A
Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
PERSONAL
HISTORY
Birth &
Development
milestones
Quality of family life
Schooling
Adolescent & social
development
Work history
Sexual & Marital
relationships
Forensic History
PAST PSYCH
HISTORY
What
When
Past treatments,
medications &
outcome
ALL CURRENT
MEDICATION &
COMPLIANCE
Type,
Effectiveness,
Acceptance of
medication
Side effects
MEDICAL
HISTORY
Current symptoms
Past il nesses
Operations
Allergies
Hep ABC HIV
Brain Injury
BP problems
Cholesterol
Diabetes
Cardiac issues
Thyroid
Family medical hx
Version: 6 : Issue date: January 2017
Page 3 of 7
FORM MHS CAF-A
Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
FAMILY PSYCH
HISTORY
SOCIAL
SITUATION
Marital Status
Family Support
Friends
Accommodation
Forensic Status
activities of daily
living function/work/
vocational
programme and
strengths?
FAMILY
STRUCTURE
Parents
Siblings
Offspring
Deaths
Quality of
relationships
CHILDREN
Number of dependent children:_____________________________
No. of dependent
children?
Names and ages of dependents:___________________________________________________
_____________________________________________________________________________
Effect of il ness
On dependent
children,
Who cares for
children when
unwell?
Family support for
parenting?
Care Planning
Care Plan Required Yes No
Information Provided Yes No
Family violence
FV Screen
CYFS referral Safety plan discussed Referral to other support agencies
screening (FVS).
indicated
completed
i.e. Police, women’s refugee, local
The staff in this DHB
Yes No
Iwi services, please indicate
are concerned about
Yes No
Yes No
………………………………..
FV and its impact on
If no, please indicate
women and children,
therefore we ask al
why
FV resources provided Yes NO
women about any
below.
violence in their
home.
Framing
questions
For FV:-
Version: 6 : Issue date: January 2017
Page 4 of 7
FORM MHS CAF-A
Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
Have you ever
been subject to
violence (physical,
sexual or
emotional) in the
last 12 months?
Do you feel safe in
your home and in
your relationships
Any concerns for
safety or welfare of
your children?
Premorbid
Personality
CULTURE &
SPIRITUAL
NEEDS
Ethnic & religious
affiliations
Include
hapu/iwi if Maori
MENTAL
STATUS
EXAMINATION
Behaviour
Appearance &
Movement &
Affect & Mood
Thought process &
content, Perception
Cognition, Speech
Orientation
Memory, Recall
Concentration
Motivation
Insight &
Intellectual
functioning
Knowledge
Concrete thinking
Version: 6 : Issue date: January 2017
Page 5 of 7
FORM MHS CAF-A
Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
Rapport
RISK
FORMULATION
e.g. 5 P’s model
■ Problem:.
■ Predisposing
factors:
■ Precipitating
factors:
■ Perpetuating
factors:
■ Protective
factors:
(Can include
interventions in
place.)
DIAGNOSIS/
IMPRESSION
INITIAL
MANAGEMENT
Plan Rationale Evaluation
PLAN
Risk
Psycho-social
needs
Medication
Crisis plan
Version: 6 : Issue date: January 2017
Page 6 of 7
FORM MHS CAF-A
Name:
NHI:
Address:
MH&AS COMPREHENSIVE
DOB:
Ethnicity:
ASSESSMENT FORM - ADULT
Attach patient label
PHYSICAL EXAMINATION
General:
Physi
al description:
Height :
Weight:
Eyes:
(colour/glasses)
Hair:
Teeth:
Distinguishing features:
Urinalysis:
Temperature:
Skin:
Rash:
Jaundice:
Cyanosis:
Clubbing:
Lymphadenopathy:
Pallor:
Anaemia:
VS:
Pulse:
BP:
/
JVP:
BP: /
Apex:
ABDO:
HS:
Liver
Spleen
Oedema:
Peripheral Pulses:
Trachea:
Resp:
Percussion:
Kidney
Kidney
Breath Sounds:
Added:
NEURO:
GCS
/15
PERIPHERIES
REFLEXES
Orientated time/place/person
Upper Limb
CN II
Visual Acuity
General:
Fundi
CN III
Pupils
Tone:
CN III, IV, VI
Eye movements
Power:
Nystagmus
Sensation:
CN V
Sensation
Co-ordination:
Musculature
Corneal Reflex
Lower Limb
CN VI
Power
General:
CN VI I
Hearing
CN IX, X Soft Palate
Tone:
CAG
Power:
CN XI
Musculature
Sensation:
CN XI
Tongue
Co-ordination
MEDICAL DIAGNOSIS:
INVESTIGATIONS:
FBC
U&E
Cm
Gluc
LFTS
TFT
ECG
Chest X-ray
Other:
Version: 6 : Issue date: January 2017
Page 7 of 7
FORM MHS CAF-A
Document Outline
