Form Ab-1424 - Historical Information Provided By Family Member Or Other Interested Party Page 3

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Alameda County Behavioral Health Care Services
Historical Information Provided by Family Member or Other Interested Party
Name of Consumer ________________________ Date of Birth __________ Phone _____________
History of Consumer’s Decompensation
Please check off symptoms or behaviors that consumer has had in past when decompensating and indicate which
ones you are observing with the consumer now.
Symptom or Behavior
Past Now
Symptom or Behavior
Past Now
suicide gesture/attempts
weepiness
suicidal statements
being too quiet
thinking about suicide
expressing feelings of
worthlessness
cutting on self
afraid to leave the house
harming self
giving away belongings
sleeping too much
increased irritability and/or
negativity
not sleeping
laughing inappropriately
not eating
stopping medication
suspicious (paranoia)
repetitive behaviors
fire setting
forgetfulness
aggressive behavior (fighting)
not paying bills
threats
taking more medication than
prescribed
irrational thought patterns (not making
failing to go to doctor’s
sense)
appointments
destruction of property
spending too much money
sexual harassing/preoccupation
poor hygiene
hearing voices
overeating
lack of motivation
impulsive behavior
anxious and fearful
not answering phone/turning off
phone machine
avoiding others or isolating
talking to self
talking too much or too fast
substance abuse
argumentative
homelessness or running away
Please describe recent history and behaviors that indicate dangerousness to self, dangerousness to others
and/or make the consumer unable to care for him/herself.
Page 3 of 3
AB 1424 form rev. 10/2006

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