Biopsychosocial Assessment Evaluation

I. Client Information

Name: Golda Larson
Date of Birth: May 15, 2052
Age: 30
Gender: Male
Evaluation Date: March 8, 2082
Evaluator Name: [YOUR NAME]
Organization: [YOUR COMPANY NAME]

II. Purpose of the Assessment

The purpose of this biopsychosocial assessment is to comprehensively evaluate the biological, psychological, and social factors influencing Golda Larson’s well-being and functioning. The findings will guide a tailored intervention plan addressing identified strengths and challenges.

III. Assessment Sections

A. Biological Factors

1. Medical History

   • Chronic illnesses: Hypertension diagnosed in 2080

   • Allergies: Seasonal pollen allergy

   • Current medications: Lisinopril 10mg daily for hypertension

   • Significant surgeries or hospitalizations: Appendectomy in 2075

2. Substance Use History

   • Alcohol use: Moderate, drinks socially about twice a month

   • Drug use: None reported

   • Tobacco use: Former smoker, quit in 2078

3. Family Medical History

   • Conditions: Father has Type 2 diabetes; mother has hypertension

   • Genetic predispositions: Cardiovascular issues

B. Psychological Factors

1. Mental Health History

   • Previous diagnoses: Generalized Anxiety Disorder (GAD) in 2078

   • Treatment history: Therapy from 2078–2080; no current treatment

   • Current symptoms: Occasional insomnia and mild anxiety during stressful periods

2. Cognitive Functioning

   • Memory: Normal, no reported issues

   • Attention span: Slightly diminished during high-stress situations

   • Decision-making ability: Generally good, seeks reassurance in critical matters

3. Emotional Health

   • Stress level: Moderate, related to work deadlines

   • Coping mechanisms: Journaling, exercise, and occasional meditation

   • Mood fluctuations: Experiences minor mood dips but rebounds quickly

C. Social Factors

1. Family and Support Systems

   • Family dynamics: Positive relationship with parents and younger sister

   • Support network: Close circle of three friends and a supportive mentor at work

   • Marital/relationship status: Single, no significant relationship currently

2. Work and Financial Situation

   • Employment status: Software engineer at a mid-sized tech company

   • Financial stability: Stable income, minimal debt aside from a small education loan

3. Cultural and Community Influences

   • Cultural background: African-American, values faith and cultural traditions

   • Community involvement: Active member of a local coding mentorship program

IV. Assessment Table

Criteria	Observations	Recommendations
Medical History	Hypertension; family history of diabetes	Continue prescribed medication and regular checkups. Monitor blood pressure regularly.
Substance Use	Social alcohol use, no drug use	Maintain moderation in alcohol consumption. Avoid smoking relapse.
Mental Health	Occasional anxiety	Consider revisiting therapy or mindfulness practices during stressful periods.
Cognitive Functioning	Minor attention dips under stress	Develop structured workflows to minimize distractions.
Emotional Health	Moderate stress due to work	Incorporate more frequent stress-relief activities, such as yoga or art classes.
Family/Support System	Strong familial and social connections	Encourage continued engagement with supportive network.
Work/Financial Situation	Stable, with minimal debt	Maintain budget and consider an emergency savings plan.
Cultural/Community Factors	Active mentorship involvement	Explore additional leadership roles in the community for personal growth.

V. Summary of Findings

Based on the assessment, Golda Larson exhibits the following strengths and challenges:

A. Strengths

1. Strong support network of family and friends

2. Stable financial situation with good career progression

3. Active community involvement

B. Challenges

1. Managing work-related stress effectively

2. Sustaining mental health improvements post-therapy

3. Long-term monitoring of hypertension

VI. Recommendations

A. Short-Term Goals

1. Schedule regular physical activity to manage hypertension and stress.

2. Attend a monthly stress-management workshop or support group.

B. Long-Term Goals

1. Build an emergency fund covering six months of expenses.

2. Pursue a team lead position at work to leverage skills and boost confidence.

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Evaluator's Signature: _____________________________
Date: March 8, 2082

Organization Stamp (if applicable):
[YOUR COMPANY NAME]

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