Optional Health Assessment Modules Form (Page 5 of 27) in pdf

OPTIONAL MODULE 3:

UR Number:

MENTAL HEALTH

Surname:

Given name:

(Modified Mini Screen)

Date of birth:

(Please fill in if no label available)

PURPOSE OF MODULE

INTRODUCTION FOR CLIENT

To assess the client’s perceived physical health.

To ascertain whether the client might be experiencing some possible

“Now I am going to ask you your physical health and conduct a basic

“Now I’m just going to ask you a few more questions about your mental

undiagnosed mental health issues.

physical health check.”

health and wellbeing.”

WHO CAN ADMINISTER THIS MODULE?

INSTRUCTIONS

Only complete this module if you are a medical doctor or a nurse.

WHO CAN ADMINISTER THIS MODULE?

1. Introduce module to client.

1. For each question, please circle the response that best describes how

This is a clinician-administered module. If the client is under the

2. As questions and perform relevant tests.

your client has been feeling.

influence of alcohol or drugs at the time of assessment this can affect

3. Formulate responses and note actions to be taken.

2. Total the number of “Yes” responses and compare to established cut-

results obtained in this module, and so it’s best to administer this

offs at the end of the module.

module at a later date.

3. Consider intervention or referral to a mental health service if there is

a moderate to high likelihood of mental illness. If item 4 is present,

apply appropriate suicide risk measures.

Have you been consistently depressed or down, most of the day, nearly every day for the past two weeks?

Yes

In the past two weeks, have you been less interested in most things or less able to enjoy the things you used to enjoy most of

Yes

the time?

Have you felt sad, low or depressed most of the time for the last two years?

Yes

In the past month, did you think that you would be better off dead or wish you were dead?

Yes

Have you ever had a period of time when you were feeling up, hyper or so full of energy or full of yourself that you got into

Yes

trouble or that other people thought you were not your usual self? (Do not consider times when you were intoxicated on drugs

or alcohol.)

Have you ever been so irritable, grouchy or annoyed for several days, that you had arguments, verbal or physical fights, or

Yes

shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted, compared

to other people, even when you thought you were right to act this way?

Note: this question is in 2 parts.

Yes

a) Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable or uneasy even when most

people would not feel that way?

YES

b) If yes, did these intense feelings get to be their worst within 10 minutes?

YES

Interviewer: If the answer to BOTH a) and b) is YES, code the question YES.

If the answer to either or both a) and b) is NO, code the question NO.

Do you feel anxious or uneasy in places or situations where you might have the panic-like symptoms we just spoke about? Or

Yes

do you feel anxious or uneasy in situations where help might not be available or escape might be difficult?

Examples include: Being in a crowd, standing in a line, being alone away from home or alone at home, crossing a bridge,

travelling in a bus, train or car.

Have you worried excessively or been anxious about several things over the past 6 months?

Yes

Interviewer: If NO to question 9, answer NO to question 10 and proceed to question 11.

Are these worries present most days?

Yes

FOR STAFF ONLY

Clinician name:

Position:

Signature:

Date:

Optional Health Assessment Modules Form Page 5

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