The below examination is from my health record
located at the Veterans Hospital, Gainesville, Fl.
TRAUMA/PTSD SCREEN:
Some people have had terrible experiences that others never go through,
such as:
- being attacked - no
- being sexually assaulted or raped - no
- being in a flood or natural disaster - no
- being in combat - yes
- being in a bad accident - no
- being threatened with a weapon - yes
- seeing someone badly injured or killed - yes
(a) Did any of these experiences ever happen to you? (X)yes ()no ()N/A
If you answered "no" to question a, skip questions b, c, and d.
(b) In the past month, have you been bothered by repeated, disturbing
memories, thoughts or images of one or more of the stressful events
experienced above? ()yes (X)no ()N/A
(c) In the past month, have you felt distant or cut off from other people?
()yes (X)no ()N/A
(d) In the past month, have you been "super alert" or watchful or on
guard? ()yes (X)no ()N/A
Scoring: If patient answers affirmatively to question a and endorses ONE
of the subsequent questions (b, c, or d) refer to a mental health
professional for further evaluation and treatment of probable PTSD.
DEPRESSION SCREEN
1. During the past month, have you often been bothered by feeling down,
depressed, or hopeless? ()yes (X)no
2. During the past month, have you often been bothered by little interest
or pleasure in doing things? ()yes (X)no
A positive test result = a yes response to either question.
LIVING ENVIRONMENT SCREEN
PATIENT NAME AND ADDRESS
MORRISON, ALDEN
GAINESVILLE, FLORIDA 32609
VISTA Electronic Medical Documentation
Printed at N. FLORIDA/S. GEORGIA VHS
Page 459
() Home/apartment with family
() Home/apartment alone
() Structured living environment (i.e. Oxford House, Assisted Living)
() Shelter or transient home
(X) Homeless
ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)
1. How often do you have a drink containing alcohol?
( )0. Never
( )1. Monthly or less
( )2. Two to four times a month
( )3. Two to three times a week
(X )4. Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you
are drinking?
( )0. 1 or 2
( )1. 3 or 4
( )2. 5 or 6
( )3. 7-9
(X )4. 10 or more
3. How often do you have six or more drinks on one occasion?
( )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
(X )4. Daily or almost daily
4. How often during the last year have you found that you were not able to
stop drinking once you had started?
( )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
(X )4. Daily or almost daily
5. How often during the past year have you failed to do what was normally
expected from you because of drinking?
( )0. Never
( )1. Less than monthly
( )2. Monthly
(X )3. Weekly
( )4. Daily or almost daily
MORRISON, ALDEN
GAINESVILLE, FLORIDA 32609
6. How often during the last year have you needed a first drink in the
morning to get yourself going after a heavy drinking session?
( )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
(X )4. Daily or almost daily
7. How often during the last year have you had a feeling of guilt or
remorse after drinking?
(X )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
( )4. Daily or almost daily
8. How often during the last year have you been unable to remember what
happened the night before because you had been drinking?
(X )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
( )4. Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(X )0. No
( )2. Yes, but not in the last year
( )4. Yes, during the last year
10. How often has a friend, relative, doctor, or other health worker been
concerned about your drinking or suggested you cut down?
( )0. Never
( )1. Less than monthly
(X )2. About once a month
( )3. About once a week
( )4. Several times a week
Total Score= 25
A score of 8 or above is considered indicative of a clinical alcohol
disorder, and further evaluation should be performed.
/es/ A. D.
RN, C
Signed: 11/30/2007 10:16
LOCAL TITLE: SATT RESIDENTIAL INITIAL NURSING ASSESSMENT (T)
STANDARD TITLE: NURSING NOTE
VISTA Electronic Medical Documentation
Page 461
DATE OF NOTE: NOV 30, 2007@09:43 ENTRY DATE: NOV 30, 2007@09:43:46
AUTHOR: D, L EXP COSIGNER:
URGENCY: STATUS: COMPLETED
This is a 64 year old, FEB 4,1943, DIVORCED,MALE who was admitted
to SARRTP from the Gainesville Salvation Army where he has resided for 1 1/2
months. Prior to this, vet lived in Tallahassee, FL in an apartment x 1 1/2yrs.
Vet put his belongings in storage and came to Gainesville for substance abuse
treatment. Upon arrival to Gainesville vet entered into Ambulatory Detox and
completed x 1wk. Vet referred to SARRTP by: Fred, MSW and Irma
, CAP. Vet will be followed by Ms. Irma
SARRTP. DOC - Alcohol. Vet denies h/o substance abuse treatment.
1. INITIAL NURSING ASSESSMENT
RATED DISABILITIES - NONE FOUND
___________________________________________________________________
Height: 68 in [172.7 cm] (11/30/2007 08:57)
Weight: 252 lb [114.5 kg] (11/30/2007 08:57)
Temperature: 98.2 F [36.8 C] (11/30/2007 08:57)
B/P: 130/79 (11/30/2007 08:57)
Pulse: 66 (11/30/2007 08:57)
Respiration: 18 (11/30/2007 08:57)
___________________________________________________________________
BAL: 0.0 Urine DS Sent: ()Yes ()No (X)Pending
__________________________________________________________________
NUTRITIONAL ASSESSMENT:
Appetite: ()Very poor ()Probably inadequate (X)Adequate
()Excellent
History:
Current diet: regular
Religious/Ethic/Cultural Food Preferences: denies
Appetite - good
Recent weight loss/gain - stable
Difficulty Chewing/Swallowing - denies
___________________________________________________________________
Allergies: Patient has answered NKA
___________________________________________________________________
Reason for Admission: Substance abuse treatment:
PATIENT NAME AND ADDRESS
MORRISON, ALDEN
GAINESVILLE, FLORIDA 32609
I was now in residential treatment in the Veterans
Hospital, Gainesville, Fl
Author: Alden Morrison
___________________________________________________________________
