INTERNATIONAL MENTAL HEALTH NETWORK, LTD.
P.O. Box 578
Poway, CA 92074-0578
Phone: (858) 486-9745
Fax: (858) 486-9760
E-mail: nac01@juno.com
A package of 10 test booklets and 50 answer sheets
available for $25 from IMHN: (858) 486-9745
Test Description
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S A M P L E P R O F I L E
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POST-TRAUMA SOMATIC DISTURBANCES INVENTORY
International Mental Health Network, Ltd.
TC: 7105
FACILITY ID: 009
PATIENT ID: 0891034
SOCIAL SECURITY NUMBER: 111-22-3333
LAST NAME:
FIRST NAME:
GENDER: Male
AGE: 18
RACE: Black
HIGHEST GRADE COMPLETED: 10
MARITAL STATUS: Married
OCCUPATION:
CURRENT EMPLOYMENT STATUS: Employed
INPATIENT/OUTPATIENT: Outpatient
NUMBER OF INPATIENT ADMISSIONS:
NUMBER OF OUTPATIENT ADMISSIONS:
DATE OF LAST DISCHARGE: / /
YEARS OF ALCOHOL USE:
YEARS OF DRUG USE:
SUBSTANCES USED LAST 2 YEARS:
SOURCE OF REFERRAL: Family
FINANCIAL CLASS:
DATE OF LAST PHYSICAL EXAM: 03/25/1996
ADMISSION DATE: 09/10/1997
DATE OF TESTING: 10/01/1997
____________________________________________________________________________
This clinical profile is a confidential assessment report intended for use
by professional staff only. Its purpose is to provide clinicians with a
comprehensive clinical picture of each patient under their care, and to help
maximize therapeutic effectiveness through careful assessment, treatment
planning, relapse prevention, and aftercare. Recommendations made in this
profile do not imply that existing clinical approaches should be replaced or
modified. Their intent is to further promote individualization of patient
treatment planning, multidisciplinary approach to treatment of each patient,
patient's participation in own recovery process, and continuous monitoring
and reassessment of the therapeutic process for mutual benefit of both the
patient and clinical staff. Statements in this profile are hypotheses for
further consideration in combination with other clinical factors utilized
in therapy. This profile is intended for use by a multidisciplinary clinical
team.
____________________________________________________________________________
________________________________ _______________ ______________
Reviewing Professional Title Date
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
SYSTEMIC PROFILE - PRESENT
SYSTEMS |Raw| | RANGE |FLAG
------------------+---+----------+-----+-------+-----+----------+--------+----
DERMATOLOGICAL| 0| |None |
| | | |
HEAD| 0| |None |
| | | |
EYES| 10| *** |Low |
| | | |
EARS| 20| ******* |Low |
| | | |
NOSE| 0| |None |
| | | |
DENTAL| 40| *************** |Moderate|
| | | |
MOUTH| 0| |None |
| | | |
THROAT| 0| |None |
| | | |
NECK| 40| *************** |Moderate|
| | | |
BREASTS| 0| |None |
| | | |
PULMONARY| 50| ******************* |Moderate|
| | | |
CARDIOVASCULAR| 50| ******************* |Moderate|
| | | |
HEMATOLOGICAL| 30| *********** |Mild |
| | | |
GASTROINTESTINAL| 20| ******* |Low |
| | | |
GENITOURINARY| 0| |None |
| | | |
GYNECOLOGICAL| 0| |None |
| | | |
MUSCULOSKELETAL| 50| ******************* |Moderate|
| | | |
NEUROLOGICAL| 20| ******* |Low |
| | | |
ENDOCRINE| 20| ******* |Low |
| | | |
PSYCHOLOGICAL| 70| *************************** |High |<===
------------------+---+----------+-----+-------+-----+----------+--------+----
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
SYSTEMIC PROFILE - PAST
SYSTEMS |Raw| | RANGE |FLAG
------------------+---+----------+-----+-------+-----+----------+--------+----
DERMATOLOGICAL| 0| |None |
| | | |
HEAD| 0| |None |
| | | |
EYES| 0| |None |
| | | |
EARS| 0| |None |
| | | |
NOSE| 0| |None |
| | | |
DENTAL| 10| *** |Low |
| | | |
MOUTH| 0| |None |
| | | |
THROAT| 0| |None |
| | | |
NECK| 0| |None |
| | | |
BREASTS| 0| |None |
| | | |
PULMONARY| 0| |None |
| | | |
CARDIOVASCULAR| 0| |None |
| | | |
HEMATOLOGICAL| 30| *********** |Mild |
| | | |
GASTROINTESTINAL| 20| ******* |Low |
| | | |
GENITOURINARY| 0| |None |
| | | |
GYNECOLOGICAL| 0| |None |
| | | |
MUSCULOSKELETAL| 50| ******************* |Moderate|
| | | |
NEUROLOGICAL| 20| ******* |Low |
| | | |
ENDOCRINE| 0| |None |
| | | |
PSYCHOLOGICAL| 50| ******************* |Moderate|
------------------+---+----------+-----+-------+-----+----------+--------+----
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
SYSTEMIC PROFILE - RESIDUAL
SYSTEMS |Raw| | RANGE |FLAG
------------------+---+----------+-----+-------+-----+----------+--------+----
DERMATOLOGICAL| 0| |None |
| | | |
HEAD| 0| |None |
| | | |
EYES| 0| |None |
| | | |
EARS| 0| |None |
| | | |
NOSE| 0| |None |
| | | |
DENTAL| 10| *** |Low |
| | | |
MOUTH| 0| |None |
| | | |
THROAT| 0| |None |
| | | |
NECK| 0| |None |
| | | |
BREASTS| 0| |None |
| | | |
PULMONARY| 0| |None |
| | | |
CARDIOVASCULAR| 0| |None |
| | | |
HEMATOLOGICAL| 0| |None |
| | | |
GASTROINTESTINAL| 0| |None |
| | | |
GENITOURINARY| 0| |None |
| | | |
GYNECOLOGICAL| 0| |None |
| | | |
MUSCULOSKELETAL| 0| |None |
| | | |
NEUROLOGICAL| 0| |None |
| | | |
ENDOCRINE| 0| |None |
| | | |
PSYCHOLOGICAL| 0| |None |
------------------+---+----------+-----+-------+-----+----------+--------+----
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
FUNCTIONAL INDEX PROFILE - PRESENT
SYSTEMS |Ind| | RANGE |FLAG
------------------+---+----------+-----+-------+-----+----------+--------+----
SYMPTOM ACUITY| 17| ***** |Low |
CURRENT SYMPTOM| 0| |None |
PAST SYMPTOM| 0| |None |
RESIDUAL SYMPTOM| 0| |None |
F.I. VISUAL| 29| ********** |Mild |
F.I. AUDITORY| 31| *********** |Mild |
F.I. VOCAL| 29| ********** |Mild |
F.I. OLIGFACTORY| 29| ********** |Mild |
F.I. TACTILE| 27| ********* |Mild |
F.I. LOCOMOTION| 36| ************* |Mild |
F.I. DEXTERITY| 34| ************ |Mild |
F.I. SELF CARE| 24| ******** |Low |
F.I. ADL| 25| ********* |Mild |
F.I. FAMILIAL| 24| ******** |Low |
F.I. INTERPERSONAL| 28| ********** |Mild |
F.I. SOCIAL| 27| ********* |Mild |
F.I. OCCUPATIONAL| 28| ********** |Mild |
F.I. TEMPORARY| 7| * |Low |
F.I. LONG TERM| 19| ****** |Low |
F.I. PERMANENT| 29| ********** |Mild |
F.I. HIGH IMPACT| 16| ***** |Low |
PAIN ACCUTE| 13| **** |Low |
PAIN CHRONIC| 13| **** |Low |
HEALTH RISK PROXIM| 21| ******* |Low |
HEALTH RISK DISTAL| 31| *********** |Mild |
SYMPTOMS OF ABUSE| 15| ***** |Low |
SYMPTOM EVENT COIN| 25| ********* |Mild |
SUBSTANCE ABUSE| 31| *********** |Mild |
------------------+---+----------+-----+-------+-----+----------+--------+----
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
FUNCTIONAL INDEX PROFILE - PAST
SYSTEMS |Ind| | RANGE |FLAG
------------------+---+----------+-----+-------+-----+----------+--------+----
SYMPTOM ACUITY| 0| |None |
CURRENT SYMPTOM| 0| |None |
PAST SYMPTOM| 0| |None |
RESIDUAL SYMPTOM| 0| |None |
F.I. VISUAL| 0| |None |
F.I. AUDITORY| 0| |None |
F.I. VOCAL| 0| |None |
F.I. OLIGFACTORY| 0| |None |
F.I. TACTILE| 0| |None |
F.I. LOCOMOTION| 0| |None |
F.I. DEXTERITY| 0| |None |
F.I. SELF CARE| 0| |None |
F.I. ADL| 0| |None |
F.I. FAMILIAL| 0| |None |
F.I. INTERPERSONAL| 0| |None |
F.I. SOCIAL| 0| |None |
F.I. OCCUPATIONAL| 0| |None |
F.I. TEMPORARY| 0| |None |
F.I. LONG TERM| 0| |None |
F.I. PERMANENT| 0| |None |
F.I. HIGH IMPACT| 0| |None |
PAIN ACCUTE| 0| |None |
PAIN CHRONIC| 0| |None |
HEALTH RISK PROXIM| 0| |None |
HEALTH RISK DISTAL| 0| |None |
SYMPTOMS OF ABUSE| 0| |None |
SYMPTOM EVENT COIN| 0| |None |
SUBSTANCE ABUSE| 0| |None |
------------------+---+----------+-----+-------+-----+----------+--------+----
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
FUNCTIONAL INDEX PROFILE - RESIDUAL
SYSTEMS |Ind| | RANGE |FLAG
------------------+---+----------+-----+-------+-----+----------+--------+----
SYMPTOM ACUITY| 0| |None |
CURRENT SYMPTOM| 0| |None |
PAST SYMPTOM| 0| |None |
RESIDUAL SYMPTOM| 0| |None |
F.I. VISUAL| 0| |None |
F.I. AUDITORY| 0| |None |
F.I. VOCAL| 0| |None |
F.I. OLIGFACTORY| 0| |None |
F.I. TACTILE| 0| |None |
F.I. LOCOMOTION| 0| |None |
F.I. DEXTERITY| 0| |None |
F.I. SELF CARE| 0| |None |
F.I. ADL| 0| |None |
F.I. FAMILIAL| 0| |None |
F.I. INTERPERSONAL| 0| |None |
F.I. SOCIAL| 0| |None |
F.I. OCCUPATIONAL| 0| |None |
F.I. TEMPORARY| 0| |None |
F.I. LONG TERM| 0| |None |
F.I. PERMANENT| 0| |None |
F.I. HIGH IMPACT| 0| |None |
PAIN ACCUTE| 0| |None |
PAIN CHRONIC| 0| |None |
HEALTH RISK PROXIM| 0| |None |
HEALTH RISK DISTAL| 0| |None |
SYMPTOMS OF ABUSE| 0| |None |
SYMPTOM EVENT COIN| 0| |None |
SUBSTANCE ABUSE| 0| |None |
------------------+---+----------+-----+-------+-----+----------+--------+----
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCALE
SCORE | 0 50 100
--------+-+--------------Â--------------+--------------Â--------------+-
|
56 | **********************************
|
Moderate symptoms (e.g., flat affect and circumstantial speech, occational
panic attacks) OR moderate difficulty in socil, occupational, or school
functioning (e.g., few friends, conflicts with peers or co-workers).
A modified version of the Global Assessment Scale (GAS) (Endicott J.
Spitzer RL, Fleiss RL, Cohen J: "The Global Assessment Scale: A Procedure
for Measuring Overall Severity of Psychiatric Disturbance.") was included
in DSM-III-R as the Global Assessment of Functioning (GAF) Scale.
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.
________________________________________________________________________________
Patient Id: 0891034 11/24/1996
ICD-9 / DRG CODE TABLE
ITEMS ICD-9 MDC DRG MVRW INDEX
2. 995.3 21 447 448 0.4221
4. 711 716 08 240 241 244 245 0.7411
5. 493 04 096-098 0.8161
6. 596 11 331-333 0.8234
14. 250 10 294 295 0.7606
41. 511 04 089-091 0.8885
56. 531 534 06 174 175 0.7650
72. 995.2 21 449-451 0.5827
77. 781.1 01 034 035 0.8516
80. 054.9 09 283 284 0.6004
87. 558.9 06 182-184 0.6214
97. 785.2 05 135-137 0.6767
99. 525.9 03 185-187 0.5893
100. 787.3 06 182-184 0.6214
101. 611.79 09 276 0.6085
106. 388.70 03 073 074 0.5501
122. 298.2 19 432 0.7113
123. 379.92 02 046-048 0.5151
129. 680 698 09 277-279 0.6893
131. 786.09 04 099 100 0.6336
132. 782.2 09 283 284 0.6004
138. 698.9 09 283 284 0.6004
142. 782.0 01 034 035 0.8516
145. 781.0 01 034 035 0.8516
148. 788.6 11 325-327 0.5914
156. 719.59 08 247 0.5682
157. 368.13 02 046-048 0.5151
172. 719.09 08 256 0.6505
173. 910.8 09 280-282 0.4851
182. 536.8 06 182-184 0.6214
186. 781.1 01 034 035 0.8516
188. 780.3 01 024-026 0.8504
197. 781.1 01 034 035 0.8516
201. 782.9 09 283 284 0.6004
206. 719.09 08 256 0.6505
207. 382.9 03 068-070 0.6114
213. 786.59 05 143 0.5164
214. 626.2 13 358 359 0.9395
233. 564.0 06 182-184 0.6214
234. 344.9 01 034 035 0.8516
243. 786.8 04 099 100 0.6336
247. 780.7 23 463 464 0.5922
248. 719.59 08 247 0.5682
249. 578.1 06 174 175 0.7650
268. 781.9 01 296-298 0.6486
271. 368.42 02 046-048 0.5151
281. 303.91 20 434-437 0.8267
COPYRIGHT (C) 1996 IMH-NETWORK, LTD.