Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 11
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13FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
ADDENDUM 2 - MENTAL HEALTH SUMMARY: To be completed by a Qualified Clinical Provider
Complete addendum if the patient has current or past
history
of mental health
(duration of 6 months or longer)
(within the last 5 years)
diagnosis
.
(to include attention deficit disorders)
1. DIAGNOSIS(ES). Please complete as accurately as possible using ICD-9-CM or, when approved, ICD-10-CM.
b.
c.
a. DIAGNOSIS
ICD OR DSM
AGE AT
(Required)
DIAGNOSIS
2. MEDICATION HISTORY RELATED TO THE DIAGNOSIS LISTED ABOVE.
a. CURRENT MEDICATION(S)
b. DOSAGE
c. FREQUENCY
d. DISCONTINUED MEDICATION(S) RELATED TO DIAGNOSIS(ES) (Include reason for discontinuing)
e. FREQUENCY
3.a. THERAPIES RECEIVED OR RECOMMENDED.
b.
(Include past compliance with treatment programs, expected
length of treatment, required participation of family members, and if treatment is ongoing.)
FREQUENCY
4. COMPLETE FOR TREATMENT:
a. NUMBER OF OUTPATIENT VISITS
b. NUMBER OF HOSPITALIZATIONS
c. NUMBER OF RESIDENTIAL TREATMENT
DATE OF LAST
IN THE LAST YEAR:
IN THE LAST FIVE YEARS:
ADMISSIONS IN THE LAST FIVE YEARS:
ADMISSION (YYYYMMDD):
5. HISTORY
(X and provide details for each "Yes" answer)
YES
NO
WITHIN THE LAST 5 YEARS, HAS THE PATIENT HAD A:
a. HISTORY OF SUICIDAL GESTURES/ATTEMPTS? (If Yes, include dates)
b. HISTORY OF SUBSTANCE ABUSE?
c. HISTORY OF ADDICTIVE BEHAVIORS?
d. HISTORY OF EATING DISORDERS?
e. HISTORY OF OTHER COMPULSIVE BEHAVIORS?
f. HISTORY OF PROBLEMS WITH LEGAL AUTHORITY? (If Yes, specify)
g. HISTORY OF PSYCHOTIC EPISODES?
h. HISTORY OF SERVICES RECEIVED FOR ALLEGATIONS OF FAMILY MALTREATMENT? (If Yes, and services are delivered by Family Advocacy, note
case determination.)
DD FORM 2792 (ADDENDUM 2), AUG 2014
Page 9 of 11 Pages
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