Free Biopsychosocial Assessment Template
Biopsychosocial Assessment Evaluation
I. Client Information
Client's Name |
Birth Date |
Age |
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II. Assessment Sections
A. Biological Factors
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Medical History
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Chronic illnesses:
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Allergies:
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Current medications:
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Significant surgeries or hospitalizations:
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Substance Use History
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Alcohol use:
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Drug use:
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Tobacco use:
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Family Medical History
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Conditions:
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Genetic predispositions:
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B. Psychological Factors
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Mental Health History
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Previous diagnoses:
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Treatment history:
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Current symptoms:
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Cognitive Functioning
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Memory:
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Attention span:
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Decision-making ability:
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Emotional Health
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Stress level:
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Coping mechanisms:
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Mood fluctuations:
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C. Social Factors
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Family and Support Systems
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Family dynamics:
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Support network:
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Marital/relationship status:
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Work and Financial Situation
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Employment status:
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Financial stability: S
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Cultural and Community Influences
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Cultural background:
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Community involvement:
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III. Assessment Table
Criteria |
Observations |
Recommendations |
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Medical History |
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Substance Use |
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Mental Health |
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Cognitive Functioning |
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Emotional Health |
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Family/Support System |
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Work/Financial Situation |
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Cultural/Community Factors |
V. Summary of Findings
Based on the assessment, Golda Larson exhibits the following strengths and challenges:
Strength |
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Challenges |
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Recommendations:
Goals |
Duration |
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Physician's Signature