Form Bho-360-28 - Outpatient Education Needs Assessment Form
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1OUTPATIENT EDUCATION
Name: ____________________________________________________
NEEDS ASSESSMENT FORM
Outpatient Behavioral Health Services
DOB: _____________________________________________________
St. Agnes Hospital, Fond du Lac, WI
OR LABEL
BHO-360-28 (1.21.14)
ORDER FROM PRINTING
1
Information provided by:
❑ Patient (Skip #2)
❑ Parent/Legal Guardian
❑ Significant Other (relationship) ________________________
2.
Patient unable to provide information due to:
❑ Medical Instability
❑ Cognitive Impairment
❑ Minor Child - Age: ________
3.
What is your primary language? ❑ English
❑ Hmong
❑ Other __________________________
❑ Spanish
Translator needed: ❑ Yes
❑ No
4.
Do you have difficulty reading? ..................................................❑ No
❑ Yes
Do you need glasses for reading? ..............................................❑ No
❑ Yes
Do you need enlarged print for reading? ....................................❑ No
❑ Yes
Do you have difficulty hearing a normal speaking voice? ..........❑ No
❑ Yes
Comments: ___________________________________________________________________________________
5.
Do you have any changes in concentration? ❑ No
❑ Yes
If yes, please explain: ___________________________________________________________________________
6.
Do you have any changes in memory? ❑ No
❑ Yes
If yes, please explain: ___________________________________________________________________________
7.
Would you like to learn more about your mental health/substance abuse problems? ❑ No
❑ Yes
How do you prefer to learn new things? ❑ Written materials ❑ Demonstration ❑ Videos ❑ 1 to 1 explanation
❑ Other:_____________________________________________________________________________________
8.
Are your emotions affected by your health status? ❑ No change
❑ More anxious
❑ More depressed
❑ Other: ____________________________________________________________________________________
9.
Do you have any religious/cultural practices that may affect your health care choices? ❑ No
❑ Yes
If yes, please explain: ___________________________________________________________________________
10.
Do you have any financial concerns that may affect your health care choices? ❑ No
❑ Yes
If yes, please explain: ___________________________________________________________________________
11.
Do you have any physical limitations that affect your level of functioning? ❑ No
❑ Yes
If yes, please explain: ___________________________________________________________________________
PATIENT SIGNATURE
DATE
TIME
STAFF SIGNATURE
DATE
TIME
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