Mental Status a. Impulse Control □ Controlled with prompt/cues/support □ Over-controlled □ Minimal control If minimum control, does it pose a risk to: □ Self □ Others
b. Suicidal Ideation □ Ideation history □ Viable plan □ Current ideation □ Settling of affairs □ Previous attempt/s □ Available means (please detail below)
c. Hostile Intent □ Previous intimidation □ Viable plan □ Current intent □ History of violence (Please detail below) □ Available means (please detail below) DESIGNATION OF CERTAIN RELATIVES, FRIENDS, AND/OR OTHER CAREGIVERS I agree that Summit Medical Group (SMG) may disclose certain portions of my health information to a relative, friend, and/or other caregiver because such person is involved with my health care or payment relating to my health care. In that instance, SMG will disclose only information that is directly relevant to the person’s involvement with my health care or payment relating to my health care. I wish to make no designation at this time. I designate the following persons listed below as persons involved with my health care or payment relating to my health care for the purpose of SMG’s making the limited disclosures described above. I understand that I am not required to list anyone. I also understand that I may change this list at any time in writing. *Please list the 4 digit (month & day) date of birth (DOB) of the person listed or choose a password. Please note: The person will have to give his/her DOB or password in order to receive any information.
Mental Status. Cover every section of the mental status exam. Provide specific information and be as descriptive as possible. Include direct quotes by the DDDS claimant when appropriate.
Mental Status a. Impulse Control □ Controlled with prompt/cues/support □ Over-controlled □ Minimal control If minimum control, does it pose a risk to: □ Self □ Others
b. Suicidal Ideation □ Ideation history □ Viable plan □ Current ideation □ Settling of affairs □ Previous attempt/s □ Available means (please detail below)
c. Hostile Intent □ Previous intimidation □ Viable plan □ Current intent □ History of violence (Please detail below) □ Available means (please detail below) INTERNAL USE ONLY: MEDICAL RECORD # I have received a copy of the Summit Medical Group’s Notice of Privacy Practices. Patient’s Name Date of Birth Signature of Patient/Parent/Guardian Date
