PSY640 Week Four Psychological Assessment Report
Patient's Name: Ms. S. Date of Evaluation: 07/01/2014
Date of Birth: 01/01/1985 Age: 29 years
Education: 12 years Occupation: Student
Current Medications: None Handedness: Right
Evaluation Completed by: Dr. K., Licensed Psychologist
Evaluation Time: 1 hour diagnostic interview (90791); 7 hours test administration, scoring,
interpretation, and report (96118 x 7)
REASON FOR REFERRAL: Ms. S. was referred by Dr. R.N. for concerns about attentional functioning.
HISTORY OF CURRENT SYMPTOMS: The symptom description and history were obtained from an
interview with Ms. S. and a review of her available medical records.
Ms. S. reported a longstanding history of anxiety and depression since high school but stated her
symptoms have worsened over the past year; she eventually sought treatment. She reported her anxiety
continues to be moderate but is slightly improved, and her depression symptoms have improved
significantly with medication. However, she stated she has also experienced problems in attention and
concentration in the past several years, and these have not improved despite the noted improvements in
her mood symptoms. She reported being referred for a psychiatric evaluation while in the U.S. Army due
to her reports to her supervisor that she was experiencing symptoms of acute stress after hearing a
gunshot that led to her discovering one of her platoon mates had committed suicide.
Summary of Previous Investigations and Findings: No previous neurological or neuropsychological
evaluations.
PAST MEDICAL, NEUROLOGICAL, PSYCHIATRIC, SUBSTANCE USE HISTORY: (Inclusive review of
symptoms and disorders; only positive features listed) Medical history is significant for reconstructive
surgery for a bile duct cyst in 2009 (involving multiple surgeries), activity induced asthma, and irregular
menstruation (currently treated with medication). Previous psychiatric history is reported above. Ms. S.
stated she does not drink alcohol and has never used tobacco or recreational drugs. Ms. S. stated that
she gained over 200 pounds after her discharge from the Army and has attempted to obtain a referral
from her physician for bariatric surgery; however, reportedly, her physician has not been willing to
recommend her.
BIRTH, DEVELOPMENTAL, OCCUPATIONAL HISTORY: (Review of perinatal factors, early childhood
development and milestones, academic history and achievement, employment). Ms. S. denied any
problems with her birth or development. She stated math skills were always a relative weakness for her in
school, but she was never diagnosed with a learning disability or attention deficit hyperactivity disorder
(ADHD). She completed high school and started college immediately after high school but quit after one
year due to a lack of focus and financial strain. Subsequently, she enlisted in the army and received an
honorable discharge after 9 months due to being psychologically incapable of performing her assigned
duties. She worked full time as an inside salesperson until 2012, when she began working as a fitness
instructor. She is currently working part time and has been taking classes at a local college; she stated
she plans to enroll at a university full time in the fall semester for a bachelor’s degree in social work. She
has received accommodations (e.g., additional time for examinations, taking tests in a distraction free
environment, etc.) at a local school this semester due to her diagnosis of generalized anxiety disorder.
FAMILY HISTORY: (First degree relatives; only pertinent features reported). No significant family history
reported.
PSYCHOSOCIAL HISTORY AND CURRENT ADAPTATION: (Current living situation, social
relationships, activities of daily living) Ms. S. is married and lives with her husband. She has no children.
She remains fully independent in all activities of daily living. She stated her hobbies tend to focus on
CONFIDENTIAL