Psychological Screening Templates - DOC by slp21736

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									PSYCHOLOGICAL PAIN EVALUATION / RE-EVALUATION                                         INS / SP


PATIENT: ________________________________

REFERRAL: Dr. Lew / Metoyer / George / Parr / Bernauer / Flood / Knight /

               _______________________

LOCATION: Slidell Clinic, New Orleans East Clinic, Lake Charles Clinic, Metairie Clinic

DATE: _________________________, 2004


PROCEDURES AND TESTS:

       1.     RELEVANT HISTORY AND PAIN DESCRIPTION
       2.     CLINICAL DIAGNOSTIC INTERVIEW
       3.     MENTAL STATUS EXAMINATION (MSE)
       4.     BECK DEPRESSION-FAST SCREEN FOR MEDICAL PATIENTS
       5.     PAIN PATIENT PROFILE (P-3)
       6.     SUBSTANCE ABUSE SUBTLE SCREENING INVENTORY (SASSI-3)
       7.     BRIEF SYMPTOM INVENTORY 18 (BSI-18)
       8.     AMERICAN ACADEMY OF PAIN FUNCTIONAL ASSESSMENT


RELEVANT HISTORY & PAIN DESCRIPTION:

The patient is a ______ year-old Caucasian / African American / male / female who lives in

______________________________, Louisiana / Mississippi. He / She reports a history of

_____________________________________________________________________________

pain since _______________. The pain is reported to be MILD / MODERATE / SEVERE /

UNBEARABLE and rated as _______ on a 10-point scale in subjective intensity. The pain

is reported to be CONSTANT / INTERMITTENT, exacerbated by ____________________

________________________________________________________________ and alleviated

by ________________________________________________. Current medications include:

___________________________________________________. SOCIAL HISTORY reveals

the patient is single / married / divorced / widowed and lives alone / with his / her spouse.
He / She reports completing _____ years of formal education, and was employed for ______

years as a ______________________ prior to injury. The patient considers himself / herself

disabled since ___________. The patient admits / denies social drinking, and admits /

denies a personal or family history of alcoholism, drug abuse or psychiatric problems.

MENTAL STATUS EXAMINATION reveals the patient to be alert, fully oriented and

cooperative. MEMORY TESTING revealed no deficits / mild / moderate / severe / deficits

in immediate, remote and delayed memory functioning. LANGUAGE TESTING revealed

no deficits / mild / moderate / severe / deficits / intact expressive and receptive skills.

SENSORIUM was clear with no evidence of hallucinations, delusions, or psychotic

thoughts. During CLINICAL INTERVIEW, the patient reports the pain had a gradual

onset / resulted from cancer / a work-related injury / fall / arthritis / motor vehicle accident

/ spinal stenosis / degenerative disc disease. Clinically, the patient exhibits MILD /

MODERATE / SEVERE levels of DEPRESSION / ANXIETY with appropriate / blunted /

labile affect. Behaviorally, the patient displayed guarding / shifting / leaning / standing

positions




                       INSERT        (DICTATION – TAPE #                   )



TEST RESULTS:


BECK DEPRESSION SCREEN: _____ (Mild / Moderate / Severe)
PAIN PATIENT PROFILE (P3):

     A.    DEPRESSION: _____%ile (Below Average / Average / Above Average)

     B.    ANXIETY: _____%ile (Below Average / Average / Above Average)

     C.    SOMATIZATION: _____%ile (Below Average / Average / Above Average)


BRIEF SYMPTOM INVENTORY 18 (BSI-18):

     A.    DEPRESSION:_____%ile for PAIN / ONCOLOGY PSYCHIATRIC

           patients

     B.    ANXIETY:_____%ile for PAIN / ONCOLOGY / PSYCHIATRIC patients

     C.    SOMATIZATION:_____%ile for PAIN / ONCOLOGY / PSYCHIATRIC

           patients

     D.    GLOBAL SEVERITY INDEX:_____%ile for__________________ patients



SUBSTANCE ABUSE SCREEN (SASSI-3):

     A.    LOW / MODERATE / HIGH “ABUSE” RISK (___________%ile)

     B.    LOW /HIGH PROBABILITY OF SUBSTANCE DEPENDENCE



AMERICAN ACADEMY OF PAIN FUNCTIONAL ASSESSMENT:

     A.    VITALITY: MINIMAL / MODERATE / SEVERE RESTRICTIONS

     B.    MOBILITY: MINIMAL / MODERATE / SEVERE RESTRICTIONS

     C.    DAILY ACTIVITIES: MINIMAL / MODERATE / SEVERE

           RESTRICTIONS

     D.    TRAVEL: MINIMAL / MODERATE / SEVERE RESTRICTIONS

     E.    NEGATIVE AFFECT: MINIMAL / MODERATE / SEVERE

     F.    FEAR OF INJURY: MINIMAL / MODERATE / SEVERE
DIAGNOSIS:

     1.      Pain Disorder with Psychological Factors Due to Chronic Pain (307.89)

     2.      Depressive Disorder, N.O.S. (311)

     3.      Depressive Disorder, Moderate Severity (311.00)

     4.      Major Depression (with passive suicidal ideation) (296.2)

     5.      Dysthymic Disorder (300.4)

     6.      Anxiety Disorder, N.O.S. (300.00)

     7.      Generalized Anxiety Disorder (300.02)

     8.      Anxiety Disorder Due to a General Medical Condition (293.89)

     9.      Cognitive Disorder, N.O.S. (294.9)

     10.     Substance Abuse / Substance Dependence

     11.     Rule-Out ______________________________________

     12.     ______________________________________________


RECOMMENDATIONS:

     1.      Begin / Continue Pain Coping Skills Training

     2.      Begin / Continue Cognitive-Behavioral Psychotherapy for depression.

     3.      Begin / Continue Cognitive-Behavioral Psychotherapy for anxiety.

     4.      Referral to Dr. Metoyer / Lew for Medical Pain Management.

     5.      Patient is an appropriate candidate for opioid treatment.

     6.      Trial of antidepressive / antianxiety medication.

     7.      CLOSE SUPERVISION OF ALL PRESCRIPTION MEDICATIONS.

     8.      Patient is appropriate for the Spinal Cord Stimulator Trial / Implantation.

     9.      Patient is appropriate for Intrafusal Morphine Pump Trial / Implantation.
       10.   Additional testing with MMPI-2 to rule-out SYMPTOM

             MAGNIFICATION.

       11.   Additional testing with MMPI-2 to rule-out CONVERSION DISORDER.

       12.   Additional testing with MBMD to measure psychological and behavioral

             factors that can influence chronic pain / medical treatment.

       13.   Referral to Dr. Matthews / Bloom / Kirkham for Psychiatric Evaluation and

             medication management.

       14.   Referral to _________________________________________

       15.   Return in l 2 3 4 5 6 7 8 9 10 11 12 weeks / PRN.


Sincerely,




Dr. John M. Boutté, PH.D
Clinical Psychologist

cc:    Dr. Lew / Metoyer / Bernauer / Flood / Parr / George / Knight / Matthews / Bloom

       /________________________________

cc:    Attorney ______________________________

								
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