Free Biopsychosocial Assessment Template

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Free Biopsychosocial Assessment Template

Biopsychosocial Assessment Evaluation

I. Client Information

Client's Name

Birth Date

Age

II. Assessment Sections

A. Biological Factors

  1. Medical History

    • Chronic illnesses:

    • Allergies:

    • Current medications:

    • Significant surgeries or hospitalizations:

  2. Substance Use History

    • Alcohol use:

    • Drug use:

    • Tobacco use:

  3. Family Medical History

    • Conditions:

    • Genetic predispositions:

B. Psychological Factors

  1. Mental Health History

    • Previous diagnoses:

    • Treatment history:

    • Current symptoms:

  2. Cognitive Functioning

    • Memory:

    • Attention span:

    • Decision-making ability:

  3. Emotional Health

    • Stress level:

    • Coping mechanisms:

    • Mood fluctuations:

C. Social Factors

  1. Family and Support Systems

    • Family dynamics:

    • Support network:

    • Marital/relationship status:

  2. Work and Financial Situation

    • Employment status:

    • Financial stability: S

  3. Cultural and Community Influences

    • Cultural background:

    • Community involvement:

III. Assessment Table

Criteria

Observations

Recommendations

Medical History

Substance Use

Mental Health

Cognitive Functioning

Emotional Health

Family/Support System

Work/Financial Situation

Cultural/Community Factors

V. Summary of Findings

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

Strength

Challenges


Recommendations:

Goals

Duration


Physician's Signature

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