CONSENT FOR Ri FORMATION

Forest Hospital
An Affiliate of Forest Health Systems, inc
ba&Jt o**
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(Birthdate)* '
, _ _ _ &U1fo ,U*'-- _ L ,'"iQ
'Address)
Authorize --'A&^ ^^V^A"
a
(Name of Facility)
to release the following information from my medical, psychiatric and substance abuse (if applicable) records:
J Discharge Summary 3f. Psychological/Neuropsychological Testing
~] Psychiatric Evaluation Consultations ,
Q Medical History & Physical X-Rays 3* Educational Reports
3 Social Assessment Or Lab Reports Q 'Other (Specify) j ^J gp. '
Vision Screening EEG/EKG \
Audiogram
To be sent to: on 1 . P raAl
Forthe purpose of:
Information released is not to be further disclosed or used for any purpose other than that stated in this authorization. It is
understood that I have the right to revoke this consent in writing at any time. Any revocation shall be in writing, signed by me
and the signature witnessed by a person who can attest to my identity. No written revocation of consent shall be effective
until it is received by the person otherwise authorized to disclose records and shall have no effect on disclosures made prior
thereto. I understand I have the right to inspect and copy the information released. I further understand that my refusal to
consent to the release of the information specified above will prevent disclosure of such information to the facility or person
named herein for the stated purpose. This authorization is valid until .
(Calendar Date)
(Patient's Signature)
(Parent's or Guardian's Signature) (Relationship)
!Mi __
Date
Date
(Witness' Signature)
Date
Signatures Required: Adult patient (18 or over) and witness: Parent (or guardian) and child plus witness, if child is 12
through 17; Parent (or guardian) and witness, if child is under 12 or patient is adjudicated incompetent.
11/87 Rev.: 2/91
MCO40
r c e v II t i t - i vi:-. -.. ut i
trsrw*. A~tC\A * 7HQ ^ Q C * 1 f W
j?<H*dJ &U*/itAJ' W Vilson Lane, Des Plaines, Illinois 60016 [*]
^ ^ ^ ^ r t _ - nn . i u, l nl fln* It iHrrtf! Rtnti i "
FACE SHEI T
Madical PMXXA *
28290
Admit Date
0 4 - 2 8 - 8 9
rime
10: 30 PM
Financial Acct. #
3Q0S 0622
Family Name
S P I ZZI R R I
First
C HR I S T I NA
Middle Home Phone
3 6 2 - 9 4 9 7
Address
17479 DARTMOOR
City
Age-Yrs
14
Birth Date Month Day Year
0 8 - 0 6 - 7 4
GRAY SLAKE, I L 600
Birthplace
WI S CONS I N
Race
City
_2_
How many years in:
County State
Occupation
STUDENT
Highest School Grade Completed
no I 9TH GRADE
Employer Address/School
WARREN HI GH SCHOOL. GURNEE, I L
Name Spouse/Custodial Parent
CAROL S P I ZZI R R I 17479 DARTMOOR, GRAY S LAKE , I L 60030
Occupation
HOMEMAKER
Employer Address
Non-Custodial Parent
Employer Address
-
Notify in Case of Emergency
CAROLGDAVI D S P I ZZI R R I
Relationship
P ARENTS 17479 DARTMOOR. GRAYSLAKE
Guarantor Name
DAVI D T . S P I ZZI R R I
Addr ess
17479 DARTMOOR
City
GRAYSLAKE
Zip
X. "CC: :.
Guarantor Employer
BAXTER
Relationship
FATHER
SS i of Patient
Phone
3 6 2 - 9 4 9 7
Phone - Employer
Phone - Employer
362- 9497
Social Security No.
3 9 5 - 8 0 - 8 4 9 7
Telephone No.
362- 9497
Occupation
SETUP OPR
EI D
1919 S . BUTTE RF I E L D RD
\
Years Employed
3 1/ 2 YRS
Phone - Employer
362- 9000/ 2121
City Zip
MUNDE L E I N, I L
Provisional (Admitting) Diagnosis
MAJ OR DEP RESSI ON
DAVI D S P I ZZI R R I
3 9 5 - 8 0 - 8 4 9 7
B04 - BAXTER^"
4900
BAXTER
MUNDE L E I N, I I
Personal Physician
Referral Source
DR. S . P E TE RS TO
&m -
Previous Psychiatnc Admissions Dates
Evai Physician
DR. DI ANE L L A
Physician ft
I Z0N36- 0S606
Dates of Last Forest Admissicn
Attending Physician
DR. DALE GI OL AS 136- 06246
Physician '! Dicdisrns 0-.'.;. - , in-,
i --,
S PM
ADMITTING PSYCHIATRIC DIAGNOSJ S (DSM-111) (to be completed, within 24 hours of admission)
Admitting Physical Diagnosis:
=INAL DIAGNOSIS:
Axis I:
; rincipal:
.:(tf!|.-.:
TCtO<?/Z) STRUCT
Major Depression, Single, non psychotic dS(^idC-
Secondary:
Axis II:
M.D.
Forest Hospital
i\, Qffj/i if
s
t fores - . -.
T
is. mc
Ralph C MenuziM, M 0
Mcdtcai Director
Chris E. Stout, l*s> 11
Chief Psychologist
R IEDICA L EI ^_
n
'
a r
" TN^^iKk/KA'iiTON REPLY
Date:
Re: Dl __
D The information requested is enclosed. The material contained herein is confidential and is being provided in
response to a written authorization, subpoena, or statute. Further disclosure by the receiving party for any
puipose other than that stated in the request is prohibited.
^ The fee for this sen/see is'. Checks are payable to Forest Hospital. Send to the attention of the
Medical Record Department.
The copies you have requested are incomplete. They will be forwarded to you upon completion of the
medical record.
The patient is now in the hospital and his medical record is not available for correspondence purposes at this
time. We will complete your request when he/she is discharged.
The patient's authorization to release his medical records is lacking. Please have the patient sign an
authorization for disclosure of confidential information. Have the parent (or legal guardian) and patient sign
consent for a minor patient between the ages of 12 and 18.
In order to process this request, we will need proof of legal guardianship.
Due to hospital policy, we require the original consent form. Upon receipt of the original consent, we will be
pleased to forward the requested information.
In order to properly identify the above-named patient, we are in need of some additional information. Please
send the patient's attending physician's name., the exact dates of admission and discharge, date of birth,
and/or change of name.
After checking our files thoroughly, we regret to inform you that we can find no record on the above-named
patient.
Due to the Illinois Mental Health & Developmental Disabilities Confidentiality Act, which requires a number
of specific items, we are enclosing an authorization which complies with this requirement. Upon receipt of
the completed authorization, signed by the appropriate person(s) and witnessed, we will be pleased to
forward the requested information.

' \j i ' ') i, "
WPLAA I /QI Medical Record Department
555 vrntirFLarW* Des Plame:
F O R E S T HO P I T A L
DES PLAINES, I LLI I wI S
DtfMflL
DISCHARGE SUMMARY
Patient #: 28290
Age: 14 Sex: F LOS
Admission Date: 4/ 28/ 89
Residence (County):
Pat-.iftnfc Name: Spi zzi r r i . Chr i st i na
50 Admission Status
Discharge Date: 6/ 17/ 89
Physician Name: Dr . Gi ol as
ADMITTING PSYCHIATRIC DIAGNOSIS: Maj or Depr essi on, si ngl e, wi t hout
psychosi s
ADMITTING SOMATIC DIAGNOSIS: No acut e medi cal pr obl ems
FINAL DIAGNOSES:
AXIS I :
Pr i nci pal Di agnosi s: , Maj or Depr essi on, si ngl e, non psychot i c
I ncl ude DSM- I I I - R Subt ype or Qual i f yi ng Ter m, i f appr opr i at e
AXIS II:
iiJ^XS JL X JL
AXIS IV:
Secondar y Di agnosi s:
Pi acrnosi s : NA
I LLI NOI
Physi cal Pi acrnosi s No acut e medi cal pr obl ems
p. qychosoci al Sf . r essor s; Chaot i c & conf l i ct ual f ami l i al
ej ^
i a
i - HnnQ- nat ur al f at her ' s r ej ect i on/ academi c dysf unct i on
SEVERITY OF STRESSORS:
1.
2."
None
"Minimal
3. Mild
"Moderate
Severe
"Extreme
_Catastrophic
"Unspecified
CONDITION ON DISCHARGE
Recovered
7.
6/
"Remission
"Markedly Improved 2
4. X Moderately Improved
_Slightly Improved
Un improved
1.
JRegressed
"Deceased
PROGNOSIS: Fai r , dependi ng on i nt egr at i on and appl i cat i on of t her apeut i c
suggest i on and f ol l ow t hr ough of r ecommendat i ons
DIAGNOSTIC CRITERIA PRESENT: (Evaluate severity as Absent, Mild, Moderate,
or Severe.)
Diagnostic Criteria
Severity at Admission
Depr essed mood
Sever e
Absent
Sui ci dal i deat i on
Lyi ng, st eal i ng
Soci al / academi c pr obl ems
I mpr ovi ng
F O R E S T HO P I T A L ^ ^ 0
L
*7^
DES PLAINES, ILLIfcjXS - . - / - - ' / U
g o, 2.7. / A i , c n
HOSPITAL COURSE: ( Recapi t ul at e si gni f i cant f i ndi ngs and event s i n a
nar r at i ve f or m. Addr ess al l i ssues & r esponses t o psychot her apy and
chemot her apy, i ncl udi ng changes i n st at us, in monthly segments.)
Thi s 14 year ol d f emal e was admi t t ed as t r ansf er f r om St . Ther ese ER f or
eval uat i on *nd t r eat ment of sui ci dal t hr eat s and gest ur es. I n addi t i on
pat i ent had exhi bi t ed out of cont r ol unmanageabl e sel f def eat i ng and sel f
dest r uct i ve behavi or s. A goal di r ect ed psychot her apeut i c appr oach was
ut i l i zed i n conj unct i on wi t h chemot her apy, a behavi or al mi l i eu pr ogr am and
mul t i di sci pl i nar y i nvol vement i n t he t r eat ment pr ocess. Ther apeut i c
ef f or t s f ocused on i ncr eased posi t i ve pr obl em sol vi ng and copi ng ski l l s,
connect i ng consequences t o behavi or s wi t h sel f r esponsi bi l i t y f or act i ons
and er adi cat i ng sel f def eat i ng t hi nki ng and act i ons. I n addi t i on
assi st i ng par ent s wi t h ef f ect i ve execut i ve f unct i oni ng and par ent al
t echni ques wer e t her apeut i c t hemes. t Unr esol ved anger r e absent f at her
expl or ed i n. t her apy3 Exhi bi t ed di f f i cul t y i n consi st ent ef f or t s wi t h
poor l y or gani zat i on concept i ons of sel f r esul t i ng i n wi de var yi ng
behavi or s. Pr ogr ess sl ow but def i ni t e. Began t o demonst r at e abi l i t y t o
exper i ence, i dent i f y and expr ess af f ect i n mor e appr opr i at e ways.
Di schar ge cont r act was devel oped bet ween par ent s and pp. t. i ent. . Pat i ent
eut hymi c, mor e opt i mi st i c, wi t h i mpr oved abi l i t y t o di r ect l y communi cat e
t o ot her s and pr obl em sol ve mor e const r uct i vel y.
SPECIFIC MODULATES:
A. Chemot her apy: ( Li st medi cat i ons used, dosage and r esponse. )
Pr ozac 20 mq a am
B. ECT: ( Number of t r eat ment s and r esponse. )
NA
C. Ot her Modal i t i es:
BMP, school , i ndi vi dual , f ami l y, gr oup t her apy; mi l i eu gr oup; gr i ef and
l oss gr oup; adj unct i ve t her apy and associ at ed gr oups
D. Adver se React i on/ Compl i cat i ons:
NA
PSYCHOLOGICAL CONSULTATIONS/TESTING: ( I ncl ude br i ef summar y of _r esul t s. )
Psychol ogi cal s r eveal ed l ower l i mi t of aver age i nt el l ect ual abi l i t y.
Per sonal i t y pr of i l e conf i r ms depr essi on and emot i onal r eact i vi t y.
CONSULTATIONS: PSYCHIATRIC & MEDICAL: ( I ncl ude br i ef summar y of r esul t s. )
Physi cal assessment compl et ed by Medi cal Ser vi ce
A. Hi st or y:
Unr emar kabl e hi st or y as r epor t ed by pat i ent
12 UG,"^iQ^i ^;:;.;->:a.\':a -.Los ( Abnor mal Fi ndi ngs) :
No acut e or gani c pat hol ogy of si gni f i cance not ed i n physi cal exam.
F O R E S T HO P I
DES PLAINES, I LLI &wXS
T A
>] 22.. rf
K A ^ A ^
LABORATORY:
Test s Per f or med:
Cul t ur es:
X- Rays:
Other s:
X_SMA XJ J /A X_UCG X_CBC
X_DST _PAP _EKG EEG
X_Thr oat _Ur i ne Ot her s
X_Chest _Skul l Ot her s
Speci f y:
X_RPR X_Toxi col ogy X_T3/ T4
( Speci f y) :
( Speci f y) :
Abnor mal Labor at or y Fi ndi ngs:
DST - non suppr essi ve
Non- Psychi at r i c Medi cal Cour se: ,
Exper i enced essent i al l y unevent f ul medi cal cour se. Di schar ged wi t hout
over t physi cal sympt oms nor subj ect i ve medi cal compl ai nt s-
DISPOSITION:
X Appr oved/ Di schar ged t o
Wi t hout Appr oval ( AMA)
"Di schar ge per El opement
"Admi ni st r at i ve Di schar ge
"Legal Di schar ge
Par ent al or Li neal Home
"Conj ugal Home
"Al one
Col l at er al Home
FOLLOW UP:
_ X Wi t h Fol l ow Up:
Out - Pat i ent Ther apy Wi t h:
Of f i ce_ .
one week
Dr . Todd
( Name)
( Locat i on)
( Dat e/ Fi r st Appoi nt ment )
Wi t hout Fol l ow Up:
Reason:
TRANSFER TO: ( Recor d Name of Faci l i t y
Gener al Hospi t al :
Gener al Hospi t al ?
Psych Uni t :
Psych Hospi t al :
Nur si ng Home:
Hal f way House:
Resi dent i al Tx Faci l i t y/
School :
F O R E S T HO P I T A L
DES PLAINES, ILLIl wi i S
MEDICATIONS ON DISCHARGE:
Drug Name
Mi l l i grams
Frequency
Per Day
Amount
30 j
Refills
1
J Prozac
20 1
q am
Amount
30 j
Refills
1
I P'"
1
1 > P B B 8 ^ r o i r irr'imiiiia
[ 1 1
RECOMMENDATIONS ON DISCHARGE:
School st af f i ng ar r anged, t o r et ur n t o home, cont i nue wi t h i ndi vi dual and
f ami l y t her apy; cont i nue wi t h Pr ozac compl i ance; medi al management wi l l
be done by t hi s cl i ni ci an. " \ ; \ / \ ,
DATE:
ATTENDING PHYSICIAN: M.D
Dal e Gi ol as, M*p.
j b
fOREST HOSPITAL
PSYCHIATRIC EVALl ION
GBEHHtt.
PSYCHIATRIC EVALUATION
Wr i t t en
Dat e: 4- 28- 89 Di ct at ed Pat i ent Name: Chr i st i na Spi czi r r i
Medi cal Recor d #
I . PRESENTING COMPLAINTS OR PROBLEMS
Chr i st i na i s a 14 y. o. Caucasi an f emal e who was admi t t ed f or
depr essi on wi t h sui ci dal gest ur e.
II. DESCRIPTION OF PRESENT ILLNESS (Date of onset, symptomatology.)
Thi s i s t he pat i ent ' s f i r st psychi at r i c hospi t al i zat i on. Pat i ent was
t r ansf er r ed f r om St . Ther ese emer gency r oom af t er she had t aken 10
Dr i st an t abl et s. She al so t r i ed t o st ab her sel f wi t h a kni f e t he day
af t er mom gr ounded her f or smoki ng. St epf at her had t o r est r ai n her
physi cal l y as she r ef used t o go t o _ tj i e_ej ne_ragncy r oom. Pat i ent ,
cl ai ms she had sui ci dal t hought s about a mont h ago? al so after mot her
PI it- he. f hai r "as" a puni shment f or a si mi l ar pr obl em of smoki ng i n f r er
r oom
Mot her cl ai ms t hat si nce t he st ar t of t he school year
;
pat i ent has
been l yi ng, st eal i ng f r om home, ski ppi ng cl asses and was const ant l y-
angr y and i r r i t abl e. She was ar r est ed and char ged f or di sor der l y
conduct and dr i nki ng and vi ol at i on of cur f ew. t wo mont hs pr i or t o
admi ssi on. Mom descr i bes mood swi ngs whi ch woul d shi f t f r ombei ng
i r r i t abl e t o bei ng cal m, sweet gi r l t hr ough t he day. Mot her has
appar ent l y consul t ed a t her api st on t wo occasi ons wi t hout much
i mpr ovement . Pat i ent deni es any dr ug or al cohol abuse.
Ill PAST HISTORY (Include individual, family, educational, vocational and
social data.) * . , . _
Pat i ent i s t he mi ddl e chi l d of t hr ee gi r l s. The ol der gi r l i s 20 and
t he youngest i s 10. Par ent s di vor ced about 9 year s ago and mot her i s
ver y bi t t er about f at her havi ng l ef t t hem, wi t h no means of suppor t
and not car i ng f or t he gi r l s. Mot her has si nce r emar r i ed i n t he^i ve
year s. She vol unt eer s t hat t her e i s some ani mosi t y, bet ween her .
pr esent husband and t he pat i ent . The pat i ent cl ai ms t hat her mot her
had t o wor k t wo j obs as a nur se because her st epf at her was not
wor ki ng har d enough. Mother. appar ent l y wor ks. 90 hour s a week as a
nur se si nce l ast year . Pat i ent al so compl ai ns t hat st epf at her , unt i l
r ecent l y, puni shes her physi cal l y and on t wo occasi ons has t hr own her
agai nst t he wal l .
Ther e i s a posi t i ve f ami l y hi st or y of ment al i l l ness i n t he pat i ent ' s
f at her who mom cl ai ms was t r eat ed f or some psychi at r i c pr obl ems whi l e
ser vi ng i n t he Ar my and f or t he pat er nal gr andmot her who was i n a
ment al hospi t al i n Wi sconsi n and f i nal l y commi t t ed sui ci de by
shoot i ng her sel f i n t he head.
Mot her descr i bes a di f f i cul t bi r t h and ear l y devel opment wi t h t he
pat i ent bei ng bor n j ust 2 l bs. and was cont i nuousl y cr yi ng and
i r r i t abl e t hr oughout t he f i r st year of l i f e. Pr esent l y t he pat i ent
i s a f r eshman and dur i ng t he l ast t er m has appar ent l y been doi ng
poor l y academi cal l y.
FOREST HOSPITAL
PSYCHIATRIC EVALl ION
IV. MEDICAL HISTORY AND CURRENT MEDICAL STATUS
No ser i ous medi cal pr obl ems at pr esent .
V. MENTAL STATUS Include: General appearance & behavior. Cognitive
functioning (orientation, memory, general information, abstraction,
concentration). Thought processes and content (abnormal
associations, homicidal & suicidal ideation). Affect (range
intensity, fluctuations & lability, appropriateness). Judgement
15 y. o. Caucasi an f emal e dr essed i n hospi t al gown who l ooks her
st at ed age. Speech and gai t wer e nor mal . Her mood was mar kedl y
depr essed. She was angr y and cr yi ng t hr oughout t he i nt er vi ew. Af f ect
was appr opr i at e. Ther e wer e no per cept ual or t hought di st ur bances at
t hi s t i me or i n t he past . Pat i ent admi t s t o f eel i ngs of hopel essness
and sui ci dal t hought s. She i s or i ent ed wi t h good memor y. I nsi ght
and j udgement ar e i nt act .
VI. PROVISIONAL DIAGNOSES: Axis I Maj or Depr essi on, Si ngl e,
Non- Psychot i c
Axis II Def er r ed
Axis III No Si gni f i cant Pr obl ems at t hi s
t i me.
VII LIST SUPPORTING DSM-III-R DIAGNOSTIC CRITERIA WITH SEVERITY
Mild Moderate Severe
1. Depr essed mood wi t h sui ci dal
i deat i on and gest ur e
2. Behavi or al pr obl ems of l yi ng
st eal i ng, ski ppi ng cl asses
3. I mpai r ment i n soci al and
academi c f unct i oni ng
4.
5.
VIII JUSTIFICATION FOR HOSPITALIZATION
Depr essi on wi t h sui ci dal gest ur e.
IX. PRELIMINARY TREATMENT PLAN
Admi t t o For est Hospi t al
Do compl et e medi cal wor kup
Soci al hi st or y and psychol ogi cal t est i ng t o det er mi ne f ami l y
dynami cs and st r essor s i n t he f ami l y
I ndi vi dual , gr oup and mi l i eu t her apy
Fami l y t her apy
X. CLINICAL JUSTIFICATIONS) OF DENIAL OR LIMITATIONS OF PATIENTS CIVIL
RIGHTS SI pr ecaut i ons because of sui ci dal gest ur e and i deat i on.
Uncl ot hed body and bel ongi ng sear ch f or unaut hor i zed mat er i al t o
i S '. _. . A
X *
X ?
x 1
FOREST HOSPITAL ,
PSYCHIATRIC EVALt ION j C L ; S L
. . j , , - r- , -
pr event i nt er f er ence wi t h t r eat ment . Phone and vi si t i ng t o f ami l y
onl y t o pr event har r assment by peer s.
XI. DISCHARGE CRITERIA Al l evi at i on of depr essi on and sui ci dal i deat i on
i mpr ovement i n f unct i oni ng.
XII. ESTIMATED LENGTH OF STAY 4- 6 weeks
XIII ANTICIPATED AFTERCARE PLAN Cont i nui ng out pat i ent i ndi vi dual and
f ami l y t her apy.
/ ^ ^ ' i ^ o~ J
Exami ner ^ ^^K- - ^-' * ' , M. D.
Di anel l a Di zon' , M. D.
Recei ved_4- 2 9- 8 9_Typed 4- 2 9- 8 9 r w
res )sp i *
Des Plaines, I I l i n o i ^ f
l
* * *
t*
it i A
Pat i ent Name:
Hospi t al #:
Physi ci an:
Pr ovi si onal Di agnosi s
Dat e of Admi ssi on:
Dat e of I nt er vi ew:
Dat e of Bi r t h:
Pl ace of Bi r t h:
Age:
Sex:
Race/ Rel i gi on:
Educat i onal Level :
Fi nanci al St at us:
Occupat i on:
Mar i t al St at us:
Mi l i t ar y St at us:
Legal St at us:
Fami l y Composi t i on:
Pr esent Pl ace of Resi dence:
I nf or mant s:
Name
:
Rel at i onshi p t o Pat i ent :
Age:
Occupat i on:
NOTE: The t er m i nf or mant s
DEPARTMENT OF SOCI AL WORK
SOCI AL ASSESSMENT
C O N F I D E N T I A L
Chr i st i na Spi zzi r r i
28290
Dr . Gi ol as
Maj or Depr essi on
4- 28- 89
5- 8- 89
8- 6- 74
Wi sconsi n
14
Femal e
AftfttflriF
CBKHim
Caucasi an/ Cat hol i c
Pr i or t o admi ssi on, pat i ent was enr ol l ed as a 9t h
gr ader at War r en Hi gh School i n Gur nee, I l l i noi s.
Dependent
St udent
Si ngl e
N/ A
N/ A
Bi ol ogi cal mot her , Car ol , age 42; si st er , Car l ot t a,
age 20; si st er , Cupr i na, age 10; st epf at her , Davi d
Spi zzi r r i , age 27; pat i ent ' s bi ol ogi cal f at her ,
Gor don Br at t , age 43, r esi des i n Mi l waukee, WI .
Pr i or t o admi ssi on, pat i ent r esi ded i n mot her ' s home
i n Gr aysl ake, I L
Car ol Spi zzi r r i / Davi d Spi zzi r r i
Mot her / St epf at her
42/ 27
1- l omemaker/ Set up oper at or
">'
11 r ef er t o pat i ent ' s mot her and st epf at her ,
I DENTI FYI NG I NFORMATI ON: Chr i st i na i s a 14 year ol d Caucasi an f emal e who was
wi t h a pr ovi si onal di agnosi s of Maj or Depr essi on wi t h sui ci dal gest ur e t o ["own
uni t on 4- 28- 89 under t he car e of Dr Gi ol as. Thi s i s t he pat i ent ' s f i r st p
v
-
hospi t al i zat i on. Pr i or t o admi ssi on, she r esi ded i n her mot her ' s home i n Gr a
I l l i noi s. She i s t he mi ddl e chi l d i n a si bshi p of t hr ee. Pat i ent i s a 9t h ,r
t t ed
; se
: t ri c
f
Chr i st i na Spi zzi r r i 4
Page 2
who at t ends War r en Hi gh School i n Gur nee, I l l i noi s.
PRESENTI NG PROBLEM/ PSYCHOSQCI AL STRESSORS: The pat i ent was t r ansf er r ed f r omSt .
Ther ese emer gency r oom af t er she t ook an over dose on t en Dr i st an t abl et s. On t he
same day, t he pat i ent had at t empt ed t o st ab her sel f wi t h a kni f e af t er her mot her
gr ounded her f or smoki ng. She had t o be r est r ai ned by her st epf at her physi cal l y
when she r ef used t o go t o t he emer gency r oom. The pat i ent cl ai med at t hat . l i me. .
t hat she had sui ci dal t hought s about a mont h aao af t er her mot her cut her hai r as
a puni shment f or smoki ng i n her room. .
Accor di ng t o t he pat i ent ' s mot her , si nce t he st ar t of t he school year , Chr i st i na
has been l yi ng, st eal i ng f r om her si st er , ski ppi ng cl asses, and appear ed
const ant l y angr y and i r r i t abl e. Two mont hs ago, she was ar r est ed and char ged wi t h
di sor der l y conduct , dr i nki ng, and vi ol at i on of cur f ew. The pat i ent ' s mot her
descr i bes Chr i st i na as one who has mood swi ngs who can shi f t f r om bei ng i r r i t abl e
t o bei ng cal m.
At t he t i me of t hi s i nt er vi ew, bot h t he pat i ent ' s mot her and st epf at her agr eed
t hat Chr i st i na has appear ed mor e depr essed and shor t t emper ed par t i cul ar l y wi t h
f ami l y member s. She was ext r emel y act i ve i n bal l et , however , gave i t up a year
ago af t er she exper i enced some knee pai n. Ther e has been a si gni f i cant decl i ne i n
t he pat i ent ' s school wor k and she i s cur r ent l y f ai l i ng t hr ee subj ect s.
PAST PSYCHI ATRI C HI STORY: Thi s i s t he pat i ent ' s f i r st psychi at r i c
hospi t al i zat i on. The pat i ent ' s mot her st at ed t hat she di d t ake Chr i st i na t o see a
p^dr i at r i s L j ? J L i ^ occasi ons around. C_br. ts. tma. 3i J me _of . . . 1988, The
pat i ent at t hat t i me was exper i enci ng school pr obl ems, depr essi on, anger , and was
st eal i ng f r om a f ami l y member .
FAMI LY PSYCHI ATRI C HI STORY: Accor di ng t o t he pat i ent ' s mot her , pat i ent ' s
bi ol ogi cal f at her was eval uat ed and t r eat ed psychi at r i cal l y whi l e i n t he Ar my.
The pat i ent ' s pat er nal gr andmot her was al so hospi t al i zed sever al t i mes i n
Wi sconsi n and commi t t ed sui ci de by shoot i ng her sel f i n t he head when she was 58
year s of age. The pat i ent ' s pat er nal aunt has al so made a sui ci de at t empt ; al so a
pat er nal uncl e has a hi st or y of sever e emot i onal pr obl ems.

SUBSTANCE ABUSE HI STORY: Accor di ng t o t he i nf or mant s, Chr i st i na has exper i ment ed
at l east on t wo occasi ons wi t h al cohol . Two mont hs ago, she was gr ounded af t er
she r epor t edl y went f or a dr i ve wi t h t wo ol der mal es al ong wi t h a gi r l f r i end.
Thi s gi r l f r i end and Chr i st i na dr ank Sout her n Comf or t l i quor whi l e i n a car wi t h
t hese mal es. Chr i st i na was dr unk as wel l as her gi r l f r i end and was pi cked up by
t he pol i ce and char ged wi t h bei ng dr unk and br eaki ng cur f ew al ong wi t h di sor der l y
conduct . Anot her t i me t he pat i ent ' s par ent s i ndi cat ed t hat a bot t l e of wi ne was
mi ssi ng f r om t hei r home and i t i s st r ongl y f el t t hat Chr i st i na t ook t he wi ne.
Ther e i s no ot her i ndi cat i on t hat she abuses or uses dr ugs.
FAMI LY SUBSTANCE ABUSE HI STORY: Accor di ng t o t he patl f i DJ LJ S- f f l al hf i E, pat i ent ' s
mat er nal gr eat gr andf at her and sever al mat er nal uncl es suf f er ed wi t h al cohol i sm.
The pat i ent ' s mot her st at ed t hat her gr andf at her f r oze t o deat h whi l e under t he
i nf l uence of al cohol .
SPUZI 8 ' : * I STI HA
Chr i st i na Spi zzi r r i ^
Page 3
SI GNI FI CANT MEDI CAL HI STORY: The pat i ent i s descr i bed as i n good heal t h. She
st ar t ed smoki ng ar ound Chr i st mas of l ast year . She r epor t edl y sneak smokes. The
pat i ent does babysi t and ear ns a l i t t l e bi t of money t hat hel ps her t o buy
ci gar et t es. I t i s agai nst her par ent s' r ul es f or Chr i st i na t o smoke i n t he home.
Si gni f i cant l y, t he_p_at i ent _br oke her nose t wo year s and was hospi t al i zed on an
out pat i ent basi s. She al so br oke a l i t t l e f i nger f our year s ago af t er sl ammi ng i t
i n t he door . Her t onsi l s wer e r emoved f our year s ago. The pat i ent ' s mot her
st at ed t hat Chr i st i na was a pr emat ur e baby who wei ghed 2 l bs. at bi r t h. She
st at ed t hat t he pat i ent has al ways suf f er ed wi t h st omach pr obl ems, aches and
pai ns, knee pr obl ems, and sever e nosebl eeds.
DEVELOPMENTAL HI STORY:
Chi l dhood: The pat i ent was bor n i n St . J oseph' s Hospi t al i n Mi l waukee, Wi sconsi n.
The pat i ent ' s mot her st at ed t hat her pr egnancy was seven mont hs i n dur at i on and
t hat she had t o have emer gency sur ger y and del i ver ed by C- sect i on. She st at es
t hat bot h she and Chr i st i na "al most di ed. " She st at ed t hat her pl acent a had spl i t
and t hi s caused sever e compl i cat i ons at t he t i me of her del i ver y. She st at es t hat
Chr i st i na r emai ned i n t he hospi t al t wo mont hs i n i nt ensi ve car e. At bi r t h, she
wei ghed 2 l bs. Car ol vi si t ed her i nf ant ever y day. Chr i st i na was 2 mont hs ol d_
when her mot her br ought her home. Her devel opment al mi l est ones wer e del ayed. The
pat i ent ' s mot her st at ed t hat Chr i st i na cr i ed const ant l y f or t he f i r st year and a
hal f . She woul d t hr ow up her f ood and di dn' t l i ke t o be hel d. She, , st at ed, . t hat , ,
she and Chr i st i na di d not bond wel l . She l at er l ear ned t hat Chr i st i na has
sensi t i ve ski n t hat was especi al l y sensi t i ve t o t ouch.
Dur i ng t hi s st age of t he pat i ent ' s dpypl onment . accor di ng t o pat i ent ' s mot her , t he
bi ol ogi cal f at her , Gor don, r ej ect ed Chr i st i na when she f i r st came home f r om t he
hospi t al . He r epor t edl y never vi si t ed her t he t wo mont hs t hat she was
hospi t al i zed. Car ol descr i bed t he mar r i age as, "I t was l i ke a hur r i cane. " Car ol
st at ed t hat her ex- husband was a t hr eat eni ng man who car r i ed a gun. She al so
st at ed t hat pat i ent ' s f at her was absent f r om t he home a l ot and st at ed t hat he had
numer ous ext r amar i t al af f ai r s. She st at ed t hat t her e was absol ut el y no bondi ng
bet ween Chr i st i na and her f at her . Gor don and Car ol had mar r i ed seven year s pr i or
t o t he bi r t h of Chr i st i na. Chr i st i na was cl ose t o si st er Car l ot t a despi t e t he age
di f f er ence. Car ol st at ed t hat her husband di d abandon t he f ami l y on sever al
occasi ons but t hat she woul d r equest hi m t o move back i nt o t he home or he di d so
when he needed money. Accor di ng t o Car ol , her ex- husband was an emot i onal l y
abusi ve man who di d physi cal l y abuse her dur i ng her pr egnancy bef or e Car l ot t a.
She st at ed t hat she mi scar r i ed af t er husband t hr ew her i nt o- a bat ht ub.
Lat ency; Accor di ng t o t he pat i ent ' s mot her , dur i ng t hi s st age of devel opment ,
Chr i st i na was wel l l oved by her t eacher s and wel l l i ked by her peer s. She woul d
of t en pout i f she di d not get her way or i f she was bor ed. She was act i vel y
i nvol ved i n t he Gi r l Scout s and chur ch gr oups, and was qui t e r el i gi ous. She
r epor t edl y was not a sel f - st ar t er and di d not t ake wel l t o havi ng t o do chor es.
She of t en t ook out her f r ust r at i on i n t he home r at her t han at school . She l ooked
up t o her ol der si st er Car l ot t a and l at er became mor e of a t eam wi t h her younger
si st er . She was 6 vear s of age when par ent s di vor ced. The pat i ent ' s mot her
st at ed t hat Chr i st i na di d not t ake t he di vor ce wel l because she di d not under st and
what was goi ng on. She used l annht . pr t.n cover UP her f eel i ngs. Chr i st i na
Chr i st i na Spi zzi r r i
Page 4
r epor t edl y can be hel pf ul , has a sense of humor , but i s ext r emel y moody,
unr esponsi ve and cl ams up. The pat i ent ' s mot her agai n r ei t er at ed t hat i t has been
di f f i cul t t hr ough t he year s t o bond wi t h Chr i st i na. Chr i st i na has a number of
di f f er ent peer s and most of t hem ar e l i ked by her par ent s. The pat i ent was
descr i bed as spoi l ed and has al ways been a good st udent and never a behavi or
pr obl em i n t he cl assr oom.
Dur i ng t hi s st age of her devel opment , t he pat i ent ' s mot her st at ed t hat t he f ami l y
si t uat i on cont i nued t o be t r aumat i c and r ocky at t i mes due t o t he mar i t al
conf l i ct s. She st at ed t hat Chr i st i na saw her f at her once a week and hadt o
t est i f y i n cour t about f at her ' s abusi veness t owar ds her mot her . The pat i ent ' s
mot her r ecei ved l egal cust ody of her t hr ee daught er s. Accor di ng t o Car ol , her
ex- husband f i l ed f or di vor ce unbeknownst t o her and t hat she showed up at cour t
t hi nki ng she was t her e r egar di ng a pr oper t y mat t er but was t her e t o f ace a j udge
about a di vor ce. She st at ed t hat her ex- husband l i qui dat ed her pr oper t i es and
t hat t hey l at er f i l ed bankr upt cy. She st at ed t hat t he pat i ent ' s f at her di d not
pay chi l d suppor t or medi cal car e f or hi s chi l dr en.
Adol escence: ^r.rnrrlinn f.o the natient's mother, she and her daught er s l ef t
Mi l waukee and moved t o I l l i noi s af t er t he di vor ce. She st at ed t hat i ni t i al l y
t her e wer e no pr obl ems wi t h her ex- husband. When Chr i st i na ent er ed j uni or hi gh
school , she t ended t o be mor e r esponsi ve, cooper at i ve, and l ess moody. She was
act i vel y i nvol ved i n bal l et , pl ayi ng t he vi ol i n, and seemed t o be much happi er .
She r ar el y shar ed her f eel i ngs wi t h her mot her but di d t al k t o her mot her about
her peer r el at i onshi ps. When Chr i st i na ent er ed 9t h gr ade, accor di ng t o her mot her
and st epf at her , she became mor e di st ant , qui et , and angr i er t owar ds f ami l y
member s. Ar ound t hi s t i me, she cont act ed her nat ur al f at her r equest i ng t o see,
hi m. The pat i ent ' s mot her st at ed t hat she di d t ake Chr i st i na and si bl i ngs t o
vi si t t hei r f at her i n Mi l waukee.
Dur i ng t hi s st age of her devel opment , Chr i st i na was wel l l i ked by t eacher s and
peer s al t hough her gr ades became f ai l i ng once. She had made A' s i n j uni or hi gh
school . She began t o di sappear ar ound t he school by ski ppi ng cl asses and t aki ng
doubl e l unches. She cont i nued t o babysi t t o ear n money. She compl ai ned about her
gr oup of peer s. She began st eal i ng j ewel r y and cl ot hi ng f r om her si st er Car l ot t a.
Many of t hese i t ems woul d show up hi dden i n a cl oset or under t he pat i ent s bed.
Thi s made her si st er mor e angr y and di st ant t owar ds Chr i st i na. Chr i st i na' s
r el at i onshi p wi t h her younger si st er al so changed. Chr i st i na st opped t aki ng
bal l et ( had t aken i t si nce age 3) .
ACADEMI C HI STORY: I n gr ades 1 t hr ough 6, pat i ent was descr i bed as a good st udent
who had never had a conduct pr obl em at school . I n gr ades 7 and 8, Chr i st i na' s
per f or mance was above aver age. She exhi bi t ed a posi t i ve at t i t ude and di d her
homewor k. Af t er ent er i ng hi gh school , gr ade 9, pat i ent began t o ski p school ,
deni ed havi ng any homewor k, and i s f ai l i ng t hr ee of her cour ses.
FAMI LY HI STORY: The pat i ent ' s mot her , Car ol Spi zzi r r i , was bor n and r ai sed i n^
Mi l waukee, Wi sconsi n. She i s an onl y chi l d. Accor di ng t o Car ol , she di d not f eel
car ed f or or l oved by her mot her who became pr egnant wi t h her when she was 42
year s of age. Car ol st at es t hat she r emember s mot her bei ng angr y t owar ds f at her
because of t he pr egnancy. I n anger , she st at ed t hat her mot her named her Car ol
i ; "
- "--* c' : [
Chr i st i na Spi zzi r r i
Page 5
af t er her f at her s i l l egi t i mat e chi l d. Car ol st at ed t hat her f at her had had a
chi l d out of wedl ock pr i or t o mar r yi ng her own mot her , r ar nl r pmpmher s her mot her
bei ng a st r i ct di sci pl i nar i an who was physi cal l y and emot i onal l y abusi ve. . On t he
ot her hand, Car ol st at ed t hat her f at her was a passi ve man who was never at home.
Her par ent s wer e di vor ced when she was 12 year s of age. She st at es t hat her
f at her vi si t ed her on occasi on and t hat he was a sel f - empl oyed home bui l der . She
st at es t hat f ol l owi ng t he di vor ce, her par ent s f i l ed f or bankr upt cy. Her f at her
l at er became an i nvest or and owned over 87 pr oper t i es by t he t i me Car ol was 30
year s of age.
Car ol st at es t hat she had al ways wor ked f or m age 12 t o t he t i me she f i ni shed hi gh
school and col l ege. She st at ed t hat her mot her pl aced l ocks on t he door when she
was out of hi gh school and came home one ni ght f r om a dat e. She st at ed t hat wi t h
t he hel p of her f at her , she was abl e t o get an apar t ment and cont i nue t o wor k.
She st at es t hat she di d not communi cat e wi t h her mot her f or an ent i r e year . She
st at es t hat she was ext r emel y pr oud of her sel f and t hat she was abl e t o pur chase
house f ur ni shi ngs and a car and suppor t ed her sel f . Car ol st at ed t hat she went
t hr ough gr ade school wi t h her ex- husband and became r e- aquai nt ed wi t h hi m af t er
col l ege. She st at es t hat her ex- husband di d r ecei ve a medi cal di schar ge f r om t he
ser vi ce due t o psychi at r i c pr obl ems. She was mar r i ed t o Gor don Br at t i n 1967
af t er dat i ng hi m a year . Car ol descr i bed t he f i r st f i ve year s of t he mar r i age as
" awf ul . " She st at ed t hat she shoul d have known what t ype of man Gor don was
because pr i or t o t he mar r i age, he was not onl y ment al l y and physi cal l y abusi ve but
a demor al i zi ng man. She compar ed hi m t o her own mot her i n t hat she f el t ext r emel y
per secut ed and abused. Accor di ng t o Car ol , her ex- husband i n 1980 di d di vor ce her
af t er he f or ced her si gnat ur e on not onl y di vor ce paper s but paper s havi ng t o do
wi t h her pr oper t i es. She st at es t hat her f at her had l ef t her 87 pr oper t i es af t er
he di ed of cancer . Car ol had wor ked on t he same f l oor wher e her f at her was
hospi t al i zed. Car ol st at ed t hat her . ex- husband was i nvol ved wi t h . t he " mob" and
needed money t o pay of f ' hi s gambl i ng debt s. She st at ed t hat he f or ged her
si gnat ur e and l at er l i qui dat ed many of her pr oper t i es. She st at es t hat she di d
not know t hat her husband was sel l i ng her pr oper t i es and t hat she was l ef t wi t h
t hr ee af t er t he di vor ce. She st at ed t hat of t he t hr ee, her husband had " one
t or ched. " Car ol st at es t hat she saw a psychi at r i st dur i ng t hi s per i od of t i me
because she was not abl e t o get i n t ouch wi t h her anger . She st at es t hat t her e
wer e occasi ons when ex- husband br oke i nt o her home and st ol e i t ems f r om her .
Car ol st at es t hat she met her cur r ent husband, Davi d Spi zzi r r i , who was a pat i ent
on a f l oor wher e she wor ked i n 1983. Davi d was under goi ng a ki dney t r anspl ant .
He l at er asked her out af t er becomi ng acquai nt ed wi t h her f or t hr ee mont hs, i hey
dat ed a year and a hal f . Dur i ng t hat year and a hal f , Davi d. j t at esj t hat . he was
wel l l i ked by Car ol ' s t hr ee dauqht er s who enj oyed f ami l y act i vi t i es. He st at ed he
had moi re " di f f i cul t y wi t h Car l ot t a because she i s cl oser t o hi s age. Daught er
Car l ot t a wi l l be 20 soon and Davi d i s 27 year s of age. Davi d mar r i ed Car ol i n
August of 1984. Davi d st at es t hat hi s f at her di ed i n J ul y of 1985 and he comes
f r om a somewhat cl ose f ami l y. Davi d st at es t hat t hi s i s hi s f i r st mar r i age and
t hat hi s daught er s ei t her cal l hi m Dad or Davi d. He st at ed t hat he used t o get
mor e r espect f r om hi s t hr ee st epdaught er s, however , i n r ecent mont hs t hey have
been mor e di st ant . He st at ed t hat of t en he st eps back and l et s Car ol make
deci si ons r egar di ng t he chi l dr en. He descr i bes si t uat i ons wher e t he chi l dr en
spl i t hi m and Car ol .
3 P i ^t l Rp i r U n f t 4 S T * n
!
Chr i st i na Spi zzi r r i
Page 6
Bot h Car ol and Davi d agr ee t hat t hey need t o wor k on communi cat i on as par ent s.
They st at ed t hat Chr i st i na wi l l be r et ur ni ng t o t hei r home. She needs t o wor k on
her sel f i shness, l ack of conf i dence i n her sel f , l ow sel f - est eem i ssues, and t he
r nmppt i t . i r m i ssue wi t h her ol der si st er .
The pat i ent ' s bi ol ogi cal f at her , Gor don Br at t , was bor n and r ai sed i n Wi sconsi n.
He cur r ent l y l i ves i n Mi l waukee, Wi sconsi n. The pat i ent ' s mot her descr i bes
pat i ent ' s f at her ' s empl oyment as a - "st ar vi ng ar t i st . " She st at ed t hat Gor don has
been a "con man" and a danger ous man as l ong as she has known hi m. Gor don i s t he
youngest i n a si bshi p of t hr ee. He cur r ent l y dat es an 18 year ol d f emal e wh
accor di ng t o Car ol has at t empt ed sui ci de. Car ol expect ed t hat she wi l l be bl amed
by ex- husband when he l ear ns t hat pat i ent i s i n t he hospi t al .
I MPRESSI ONS AND RECOMMENDATI ONS: Thi s youngst er pr esent s t o t he hospi t al f or her
f i r st psychi at r i c hospi t al i zat i on af t er she t ook an over dose of t en Dr i st an
t abl et s Pat i ent al so at t empt ed t o st ab her sel f wi t h a but cher kni f e af t er she
was gr ounded f or smoki ng by her mot her . For t he past t wo mont hs, t he pat i ent has
become i ncr easi ngl y depr essed, l yi ng, st eal i ng f r om home, ski ppi ng cl asses, and
const ant l y angr y and i r r i t abl e. She was ar r est ed and char ged wi t h di sor der l y
conduct and dr i nki ng and vi ol at i on of cur f ew t wo mont hs ago bef or e she was
admi t t ed her e. The pat i ent suf f er s wi t h mood swi ngs and has di f f i cul t y accept i ng
t he aut hor i t y of her par ent s.
The pat i ent woul d benef i t f r om a f ul l r ange of i ndi vi dual , gr oup, f ami l y, and
act i vi t y t her api es wi t hi n t he mi l i eu. Fami l y t her apy i s st r ongl y i ndi cat ed t o
hel p t he pat i ent and f ami l y member s r esol ve conf l i ct s, pr obl em sol ve, and i mpr ove
t hei r communi cat i on ski l l s. I t i s f el t t hat t he pat i ent needs t o f ocus on i ssues
of sel f - est eem, l ack of conf i dence, dependency i ssues, and compet i t i on wi t h ol der
si st er . The pat i ent shoul d be encour aged t o par t i ci pat e i n t he pr escr i bed gr oups
wUhi n t he mi l i eu and pr ovi ded suppor t t o i nvol ve her sel f i n t he pr ogr am. T_he_
pat i ent has t he capabi l i t y of i nsi ght and i s i nt el l i gent ancLver bal , and has been
i n t he past st udi ous. The pat i ent i s ar t i st i c i n t he ar ea of bal l et and pl ayi ng
t he vi ol i n. Pat i ent ' s weaknesses i ncl ude her mood swi ngs, poor j udgment , angr y
J uTbur st s~and i r r i t abi l i t y, and di f f i cul t y l ear ni ng t o manage t hese f eel i ngs and
expr ess her sel f ver bal l y t o get her needs met . . I he_. . p. ati ent seem_s_l o ha_ve. a.
conf l i ct ual r el at i onshi p wi t h her mot her and some r esent ment t owar ds . . st epf at her ,
however / t hi s" has" not been" deal t wi t h openl y. Pat i ent and par ent s, need . t o_deal
wi t h how pat i ent f eel s about her st epf at her . . and r el at i onshi p wi t h mot her .
"Pat i ent ' s' par ent s seems t o have some awar eness t hat t hey al l ow t hemsel ves t o be
spl i t by pat i ent and si bl i ngs. They compl ai n t hat t hey do have communi cat i on
pr obl ems and di f f i cul t y pr obl em sol vi ng as a par ent al uni t , i he pat i ent ' s par ent :
ar e l ovi ng and suppor t i ve of pat i ent ' s hospi t al i zat i on and need f ur t her par ent al
educat i on i n or der t o be mor e suppor t i ve and communi cat e bet t er as par ent s. The
cur r ent di schar ge pl an i s f or pat i ent t o r et ur n home and cont i nue wi t h out pat i ent
t r eat ment wi t h Dr . Tr acv Loui s Todd and Dr . Gi ol as. The pat i ent i n al l
pr obabi l i t y wi l l cont i nue out pat i ent i ndi vi dual and f ami l y t r eat ment .
SOCI AL WORK PLAN; Thi s soci al wor ker al ong wi t h t he t r eat ment t eamwi l l f or mul a'
t r eat ment goal s f or t he pat i ent . Wi l l encour age par ent s' act i ve par t i ci pat i on
t he weekl y mul t i pl e f ami l y gr oup and par ent suppor t gr oup i n or der t o pr ovi de t -
par ent s educat i on and suppor t . Wi l l assi st i n di sposi t i onal pl anni ng t o hel p
Chr i st i na Spi zzi r r i
Page 7
1 4
02, G
j 2l i
Co
3: J Q5 - ' ^--
pat i ent make smoot h t r ansi t i on back home t o her school and communi t y. The pat i ent
wi l l be r et ur ni ng home with her mot her and cont i nui ng i ndi vi dual and f ami l y
t r eat ment wi t h Dr . Tr acy Louis Todd and Dr. Gi ol as. Thi s soci al wor ker wi l l
cont i nue t o pr ovi de suppor t i ve ser vi ces and i nt er vent i ons on an as needed basi s t o
pat i ent and her f ami l y dur i ng t he cour se of her hospi t al st ay.
Dat e:
i ncy Phel / i s, ACSW
depar t ment ' of Soci al Wor k
Rec 5/ 9 & t yped 5/ 10/ 89 ( pm)
j/fa
sruii is:
LEONARD F. I JZIOL, Psy D,
DIAGNOSTIC EVAUJAT1CN AND C O N S ^ j ^ ^ EVALUATION
CDHFiOEnTlflL
Spi zzi r r i , Chr i st i na
14 year s ( Dat e of Bi r t h 8/ 6/ 74)
Femal e
8 year s compl et ed
Dal e Gi ol as, M. D.
5/ 4/ 89
5/ 5/ 89
5T
555 Wi l son t ar e
Ces Pl ames. IL 6CC/ 6
( 312] 242- 3347
Ext ensi on 4C0
Name:
Age:
Sex:
Educat i on:
Ref er r ed By:
Dat e of Eval uat i on:
Dat e of Repor t :
REASON FOR REFERRAL;
Thi s youngst er was r ecent l y hospi t al i zed because' of depr essi on and her
maki ng a sui ci de at t empt . Her behavi or s wi t hi n t he home have been unmanage-
abl e, and her academi c per f or mance has r ecent l y been det er i or at i ng. She
has been exper i enci ng mood swi ngs. I n addi t i on, she has. appar ent l y been.
t al ki ng about concer ns t hat she mi ght be possessed by t he devi l . I n vi ew
of t hi s hi st or y, psychol ogi cal eval uat i on was r equest ed t o ai d i n est abl i sh
i ng a di f f er ent i al di agnosi s.

Revi sed ( WI SC- R)

TESTS ADMI NI STERED:
Wechsl er I nt el l i gence Scal e f or Chi l dr en
Ment al St at us Quest i onnai r e
Rei can- I ndi ana Aphasi a Scr eeni ng Exami nat i on
Ror schach I nkbl ot Techni que
Rot t er Sent ence Compl et i on Test
Reynol ds Adol escent Depr essi on Scal e
Reynol ds Sui ci dal I deat i on Quest i onnai r e
Cl i ni cal I nt er vi ew
BEHAVI ORAL OBSERVATI ONS & BACKGROUND DATA:
Chr i st i na Spi zzi r r i i s a 14 year ol d Caucasi an f emal e who i s of aver age
hei ght , of sl i mbody pr opor t i ons, wi t h pr et t y f aci al f eat ur es, , and casual l y-
dr essed m j eans and a sweat shi r t . She has medi um l engt h bl ond hai r , *
vbi i g shP appear ed di sappoi nt ed when she st at ed t hat her hal t
u s e d
t o be
l onger , unt i l she had i t cut about a. mont h ago because . of a puni shment
f or smoki ng ci gar et t es. Chr i st i na was cooper at i ve. She was super f i ci al l y
pl easanV' and f r i endl y, r el at i vel y easy t o engage, and ver y accept i ng of
t he quest i ons t hat wer e asked dur i ng cl i ni cal i nt er vi ew, as wel l as t he
t asks i t wer e admi - t ar ed dur i ng f or mal t est i ng. She st at ed she was
hospi - zed because j f a sui ci de at t empt , cl ai mi ng she t ook t en Dr i st an
t abl et she st at ed t hat she at t empt ed t hi s over dose because she had
" hur t , depr essed f eel i ngs" concer ni ng t hi ngs . i n. . the past and because . she ws
angr y at "her " mot her f or not l et t i ng her go out t hat eveni ng. She i ndi cat ec
t hat she has seen a counsel or on an out pat i ent basi s f or t wo vi si t s, and
t hat whi l e he t ol d her she was ^hur t i ng" i nsi de, she i ndi cat ed she was
unabl e t o speci f i cal l y descr i be t he sour ces of her f eel i ngs.
wh
Chr i st i na st at ed t hat she has been unabl e t o get al ong wi t h her mot her
i l e she st at ed t hi s was because her mot her was "ver y emot i onal " . _SH_
i r i i t i * * : , -HRi j ti .i A
u
Spi zzi r r i , Chr i st i na
Page 2
i ndi cat ed t hat her mot her was moody, and Chr i st i na st at ed she al so r esponded
t o her mot her ' s moods. She added t hat t he pr i mar y sour ce of conf l i ct ,
however , concer ned her r el at i onshi p wi t h her st epf at her . She st at ed t hat
she di d not l i ke hi m at al l . _A_r evi ew of her medi cal r ecor d r eveal ed she
has made al l egat i ons of physi cal abuse, al t hough she di d not di r ect l y
di scuss t hi s wi t h t he' under si gned. Chr i st i na i ndi cat ed t hat her par ent s
di vor ced when she was about f our year s ol d, i n t hat whi l e she mai nt ai ned
a r el at i onshi p wi t h her f at her because she t hought he was a good per sonT
she i ndi cat ed t hev have l ost t ouch over t he past f ew year s.
Chr i st i na wor ked har d on f or mal t est i ng measur es. However , she seemed
gener al l y puzzl ed by a number of i t ems t hat wer e gear ed t owar ds onl y a
moder at e abi l i t y l evel . She never t hel ess seemed t o be t r yi ng her best .
When per f or mance- t ype t asks t axed her abi l i t i es, she woul d wor k f or a r easor
abl e l engt h of t i me, and ask f or per mi ssi on t o gui t because she had no i dea
as t o how t o sol ve t he pr obl em. Her r esponses t o pr oj ect i ve per sonal i t y
measur es f el l at an unr emar kabl e l evel . On penci l - and- paper t asks, she
asked a number of quest i ons about t hese mat er i al s whi ch suggest ed she was
concer ned about por t r ayi ng her sel f accur at el y, whi l e an anal ysi s of t hese
r esul t s di d not i mmedi at el y suggest a def ensi ve post ur e. I t i s t her ef or e
bel i eved t hat i nt er pr et i vel y usef ul t est dat a wer e gat her ed.
TEST RESULTS;
Chr i st i na obt ai ned a WI SC- R f ul l scal e I Q of 92. Thi s scor e f al l s
near t he l ower l i mi t s of t he aver age r ange of i nt el l i gence. However , her
st r engt hs l i e i n per cept ual - mot or ar eas of cogni t i on, demonst r at ed by her
per f or mance scal e I Q of 100, whi l e weaknesses concer n her l evel of l anguage-
r el at ed ski l l s, r eveal ed i n her ver bal scal e I Q of 88. I n t hi s r egar d,
she cer t ai nl y possesses t he capabi l i t i es f or successf ul l y compl et i ng her
hi gh school wor k, al t hough i nt el l ect ual abi l i t i es ar e not ext ensi ve i n
char act er and academi c expect at i ons shoul d t her ef or e be set accor di ngl y.
She obt ai ned t he f ol l owi ng scal ed scor es on t he var i ous i ndi vi dual subt est s
Ver bal Test s
I nf or mat i on
Si mi l ar i t i es
Ar i t hmet i c
Vocabul ar y
Compr ehensi on
Per f or mance Test s
Pi ct ur e Compl et i on
Pi ct ur e Ar r angement
Bl ock Desi gn
Obj ect Assembl y
Codi ng
a
a
8
u
9
10
9
9
13
Ther e i s r eal l y no demonst r abl e pat t er n' of ski l l s i n t hi s yo' ungste' rs
ver bal f unct i oni ng. Her f und of gener al i nf or mat i on i s ver y medi ocr e. A,
compar abl e st at ement can be made about her concept f or mat i on ski l l s. She
can easi l y be char act er i zed as a concr et e t hi nker . Lexi cal vocabul ar y i s
al so unr emar kabl e. The ver bal pi ct ur e t hat emer ges i s one of
an
i ndi vi dual
/
UtN>K...
m<*t
2uu i t
Spi zzi r r i , Chr i st i na
Page 3
wi t h adapt i ve ski l l s, al t hough she i s not par t i cul ar l y ar t i cul at e i n
f or mul at i ng and expr essi ng i deas.
Per cept ual - mot or ski l l s f al l sol i dl y wi t hi n an aver age r ange. She
was admi ni st er ed a var i et y of subt est s. These i ncl uded her assessi ng
t he mi ssi ng el ement s wi t hi n pi ct ur es of common obj ect s and- her t hemat i cal l j
ar r angi ng car t oon- l i ke pi ct ur es t o depi ct coher ent st or i es. These t asks
whi ch wer e dependent upon l ogi cal vi sual anal ysi s wer e per f or med i n an
unr emar kabl e f ashi on. She was al so asked t o assembl e col or ed bl ocks so
t hat t hey woul d l ook- l i ke pat t er ned model s and t o const r uct j i gsaw- t ype
puzzl es of commonl y seen envi r onment al obj ect s. Compar abl e r esul t s wer e
obt ai ned on t hese measur es of gest al t t hi nki ng whi ch r equi r ed her t o
wor k wi t h par t - t o- whol e r el at i onshi ps.
Resul t s of neur ocogni t i ve scr eeni ng demonst r at ed t hat at t ent i onal
capaci t y was i nt act . She al so per f or med adequat el y i n sol vi ng cogni t i ve
pr obl ems dependent upon f l exi bl e t hi nki ng. Her per f or mance on an aphasi a
scr eeni ng exami nat i on was wel l wi t hi n t he r ange of nor mal l i mi t s. Ther ef o;
asi de f r omdescr i bi ng her abi l i t i es as aver age, t hese t est r esul t s i mpl y
l i t t l e var i abi l i t y f r om one i nt el l ect ual ski l l ar ea t o anot her .
Revi ew of her medi cal r ecor d r eveal ed she has been pr eoccupi edwi t h
i deas c^n^er ni ng__t he_devi 1, wor r i ed t hat she mi ght i n some way, event ua1 l y
become possessed. Her t est r esul t s gi ve evi dence of her exper i enci ng a
mi l d concer n i n t hi s ar ea, and t he t est dat a f ur t her demonst r at es t hat t hi
i s a mani f est at i on of a sense of gui l t about her . Thi s gui l t r ef l ect s
t he "badness" wi t h whi ch she vi ews her act i ng- out behavi or , f f gweyer , t her
ar e no i ndi cat i ons of psychot i c t hi nki ng. At t he f undament al l evel of
per cept ual or gani zat i on, t he meani ng she assi gns t o obj ect i ve event s can
r ecei ve val i dat i on t hr ough peer gr oup agr eement . The act ual st r uct ur e of
her t hought pat t er n al so f ol l ows t he basi c r ul es of l ogi c. Her per cep-
t ual st yl e i s al so char act er i zed by her l ack of a cr yst al cl ear l ook at
t hi ngs and by a t endency t o be i mpr essi oni st i c and swayed by t he f l ow of
soci al ci r cumst ances. Thi s aspect of her f unct i oni ng al so spel l s a,
suggest i bi J Li t v, whi ch seems to_. f uxt h^r , _pr omot ^_an^yst er i cal t ype of
f ear t hat i t i s possi bl e f or her t o become nosaeasedJ However , t hi s
appr ehensi on and gui l t does not appear t o be associ at ed wi t h del usi onal
t hi nki ng at t hi s par t i cul ar t i me.
I n gener al , she mi ght be descr i bed as a youngst er who i s of t en swayed
by t he f eel i ng f l ow of si t uat i ons. One of t he most st r i ki ng f i ndi ngs of
t he per sonal i t y dat a concer ns her changabi l i t y of mood. She_cer t ai ni y
can_be_ t er med an . emot i onal l y . sensi t i Ye. _ad. ol escent , whi ch has bot h posi t i ve
and "negat i ve i mpl i cat i ons. On one hand, she i s awar e of t he r eact i ons
she evokes f r om ot her peopl e, bei ng ast ut e t o t he way she t hi nks ot her s
f eel about her because of her behavi or s. Ot her aspect s of t he dat a
suggest t hi s i s coupl ed wi t h an under l yi ng empat hi c pot ent i al so t hat she
can be war m, pot ent i al l y consi der at e, and abl e t o f or man at t achment wi t h
ot her peopl e who demonst r at e an i nt er est i n her as wel l . On t he f l i p si ds
of t hese appar ent asset s, she i s al so ver y r eact i ve. What she sees or
hear s seems t o st i mul at e her emot i ons much t oo easi l y, so t hat her moods
f l uct uat e i n di r ect r esponse t o i nt er per sonal ci r cumst ances or what she
mi ght have on her mi nd about t hem. Cer t ai n t est r esponses car r y t he
J
_ ^. * * * * * *
Spi zzi r r i , Chr i st i na
Page 4
i mpl i cat i on t hat she f i nds i t har d t o l ogi cal l y or i ent t hese f eel i ngs
i n a mor e modul at ed way, t hr ough concept s and wor ds, so t hat she f i nds i t
easi er t o adapt by expr essi ng t hese f eel i ngs t hr ough behavi or s and act i on,
i n ot her wor ds, t hr ough i mpul si ve r espondi ng.
She deni ed si gns of cl i ni cal depr essi on on a f or mal adol escent
i nvent or y. However , t hi s was i n l ar ge par t due t o her changeabi l i t y of
mood. Her t hought s and f eel i ngs ar e subj ect t o t r ansi t or y i nf l uences,
and now t hat t he ci r cumst ances t hat pr eci pi t at ed her hospi t al i zat i on ar e
past , she f eel s mor e comf or t abl e. She al so deni ed any cur r ent sui ci dal
i deat i on. However , t he ki nds of psychol ogi cal concer ns t hat r emai n on her
mi nd ar e summar i zed i n her r esponses t o t he sent ence compl et i on t est . I t
i s t her ef or e usef ul t o quot e a f ew of t hese. The wor ds, "I can' t , st i mul a-
t ed her r esponse, ^expr ess my f eel i ngs good*' , whi l e t he i t em, "I need" ,
evoked her r esponse, " suppor t *. The i t em, "I hat e" , evoked her r eact i on,
""when I ' m a f ai l ur e
1
*, whi l e t he st em, "What pai ns me" , was f i ni shed wi t h
her wr i t . i nn. - i s t hat mv mom and dad ar e di vor ced**. Ther e i s cl ear l y a
depr essi ve qual i t y t o t hi s br i ef sampl i ng of r esponses. Her sense of sel f -
wor t h i s poor l y def i ned, di f f i cul t i es i n expr essi ng f eel i ngs seem associ a-
t ed wi t h a sense of i sol at i on and bei ng mi sunder st ood wi t hi n t he f ami l y,
. wJ ai l e_s. he__re. ma. i ns. emot i onal l y dependent . and l ongi ng f or suppor t f r omot her
peopl e. .
I MERESSI ON:
Thi s i ndi vi dual f unct i ons cl oser t o t he l ower l i mi t s of t he aver age
r ange of i nt el l i gence. Ther e ar e no i mmedi at e concer ns f r om t he per -
spect i ve of neur opsychol ogi cal scr eeni ng. Cer t ai n aspect s of t he dat a
ar e i ndi cat i ve of a depr essed youngst er . . Ther e ar e al so a number of
char act er ol ogi cal concer ns. These i ncl ude her emot i onal r eact i vi t y and
her i mpul si vi t y.
I MPl - I CATI dJ SrS | .
Whi l e t hi s i s a depr essed adol escent , t he dat a al so demonst r at es t her e
i s a mar ked i ncl i nat i on f or her t o r espond t o her f eel i ngs by act i ng upon
t hem. I n t hi s r egar d, she t ends t o expr ess her sel f t hr ough her behavi or s.
She t ends t o be ver y emot i onal l y r eact i ve, whi ch gener at es i mpul si ve,
er r at i c behavi or al pat t er ns. An ef f ect i ve t r eat ment pr ogr am shoul d at t empt
t o f ocus upon devel opi ng her ski l l s f or modul at i ng and ver bal l y expr essi ng
t he way she f eel s. Thi s wi l l need t o i ncl ude di r ect i ng her at t ent i on
t owar ds exami ni ng var i ous aspect s of i nt er per sonal i nt er act i ons, so t hat
she can al so eval uat e her t hought s and f eel i ngs concer ni ng t hese i nt er per -
sonal si t uat i ons. I n ot her wor ds, she needs tq_. be gui ded i nt o l ooki ng at
her f eel i ng r esponses and si mi l ar l y i nt o expr essi ng t hem ver bal l y, whi l e
r eassur i ng her t hat her per spect i ve i s bei ng under st ood. Whi l e her act i ng-
out behavi or s i mpl y a mal adapt i ve sense of asser t i veness, devel opi ng her
ski l l s i n t he ver bal r egul at i on and expr essi on of her f eel i ngs woul d
pr omot e a. heal t hi er , mor e adapt i ve sense of asser t i on.
Fami l y i nvol vement i s ver y much advi sabl e f or an ef f ect i ve t r eat ment
pr ogr am- (i n . . he"ona hand, t hi s youngst er vi ews her behavi or s as bei ng
pr ovoked bv f ami 1v ci r cumst ances. She has a t endency t o downpl ay t he
si gni f i cance of her behavi or s wi t hi n t hi s cont ext , whi l e t hi s r ef l ect s
her changeabi l i t y i n t he way she l ooks at t hi ngs. ghe. __e_c. s ,fco_.ho,l d...the..
S ) 7 T '
WRI STI NA
C 1;
S?I ZZ1 r~, CHRIS T.I
Spi zzi rri , Chri sti na
Page 5 \ .- GI
f ami l y r esponsi bl e f or pr obl ems, and now t hat t he acut e cr i si s seems over
f or her , she i s r el uct ant t o l ook at her per sonal r ol e i n t hi s si t uat i on.
Fami l y i nvol vement needs t o cl osel y eval uat e her r el at i onshi p wi t h her
mot her , as wel l as i nvest i gat e her i deas and f eel i ngs concer ni ng her
st epf at her . Thi s youngst er s st at ement , as wel l as a r evi ew of her medi cal
r ecor d, cer t ai nl y pr ovi des consi der abl e evi dence f or a conf l i ct ual f ami l y
l i f e, wi t h mal adapt i ve ways of expr essi ng f eel i ngs and set t i ng behavi or al
l i mi t s. The dat a t her ef or e under scor es t he necessi t y f or maki ng changes
at t hi s l evel .
Leonar d F. Kozi ol , Psy. D. <f$> Q)
Cl i ni cal Psychol ogi st
LFK: j b
PHYSICAL EXAMINATION
iffniBifA
S F l Z Z I R R I , CHRI S TI NA
U ascso
b y f -* ' " "
(
h^ -'" ' ;
T* j ^ t u r _^ Z_ ' - ^0 Res pl r at l on^ i i Blood Pressure ^%V Height^" ^
a
Wst ght Ji l
1 l
( 4 s _ j 2 d l a c _ ! ^ _ Mu t t o n / Nut ri t i on.^ HaoKua ^ GENERAL Aga
Ganaral Appaaranca_^
Co o p ar at t o n ___X- Ortafttatl o_
r
Z Mood d Speach <L. 0 ^ H
H4/ / L SK//V, Half (Alopaota. Taxtura. DlaJrlbutlon), Skin (Moiatura. Tawtora. Erruptlona. Plgmant, Tumor. Ulcars. Patachiaa. Ecchy-
LYMPHATICS: mosaa. Talenglactaalc). Walls (Clubbing). Adanopathy ' _ _ _ _ _ ^ _ _ _ ^
r
H 4 0 A NECK Slza. Shapa. Symmatry. Tandarness. Scalp. Swallin
y w LIda. Conjunctiva. Sclara. Cornaa. Pupils (Size. Shapa. Raaction to light & accommodation).
Nystagmus. Strabismus. Stara. Lid Lag. Ptosis, Exophthalmos. Engphthelmoa, Lana, Fund*.
Ocular Tenalon, Acuity. Visual Raids .
* External (Tophi), Canal. Tympanic Membrane _ Hearing (Weber. RinneL
N09m External, Septum, Mucoaa, Discharge. Sinuses ^ Smell.
Mouths Breath, Ups, Teeth, Glnglva, Mucous Membranes. Tongue, Tonsils, Pharynx (Exudata). Salivary.
N9k: Trachea. Venous Distentlon, Pulsations. Tenderness. Mobility. Scars. Bruit. Thyroid
. Taate_
CHESTS Shape, Symmerty. Pulsations. Scars. Tenderness.
flftfc Masses, Tenderness. Nipples (DiscrwgeL
Lum*! Expansion. Resonance. Oiaphragmattc Motion. Breath Sounds. Adventitious Sounds.
M M * Apex, Configuration. Thrill, Rate. Rhythm (Gallop). Sounds. Rubs. Murmurs.
* Manual) Wagatfoe
GENERAL MEDL..L HISTORY
CDnFMflL
s r I z 11R RI , c H ?I s. ,
Date.
4ml *t
Age_
H
Informa
nt p
f
Reliability.
mmRAL
PAST HISTORY
'''kvttRQb Si;in, Mails, Breasts_
J
i Nervous System (Convulsions, Epilepsy, Loss of Consciousness, Stroke, Paralysis,
Migraine, Neuritis) EENT (Glaucoma, Sinusitis).
/
Blood Pressure, Heart (Rheumatic Fever, Murmur, Heart
Attack, Angina, Irregular Pulse), Blood Vessels (Arteriosclerosis, Varicose Veins, Blood Clot) _ Lungs (Pneumonia,
Bronchitis, Pleurisy, Tuberculosis)___
J
i'l3astrointestinal (Ulcer, Colitis, Diverticulitis, Hemorrhoids) Oliver (Cir-
rhosis, Hepatitis, J aundice), Gall Bladder, Pancreas___ Genitourinary (Nephritis, Stone or Colic, Blood, Sugar,
Albumin or Pus in Urine, Infection Prostate)
Hematologic (Anemia, Bleeding^GlandstZL
Meningitis, Veneral) /tumors. Cysts, Cancer
xfvlusculoskeletal (Arthritis, Rheumatism, Gout, Disc, Sciatica)
Endocrine (Diabetes, Thyroid).
umat
Infectious Diseases (Encephalitis,
Current Medications (Prescribed or Patent).
Allergic: Hayfever, Asthma, Hives, Eczema
AS.4
X / / - J 7g-fv\/
Food, Drugs (Penicillin, Barbiturates, Tranquilizers, Vaccines, Anesthetics, Atropine).
Surgical: Injuries (Head Trauma, Fractures, Hernia).
Operations (Performed or Recommended).
J-A- %^w- a jt> ?-
^/Z^
Gravida P Para . AB_ Induced,
I M P / / / 4 / 9 interval r ^f
4
^
Spontaneous.
Duration.
Menarche, Menopause.
Flow.
/
Contraceptive Drugs.
Abnormal Pregnancies or Periods, Vaginal Bleeding, Discharge, Fibroids.
immQMAL HISTORY
Marital Status: M.S.D.W. Sep. Birthplace
Places of Residence (Vacations
Occupations (Past & Present)..
Pets, Hobbies,
FAMIL)
Z//S O-s-- J /K
/y /i
U^
v
mi
O ^
Mother,
1/0
.
0
y '^-d D
fu
gs ,o Military
Father '_ o
o
y/MZJ-fPd' -
Siblings (i iving) ^"S L t H
(Deceased) J ~
Spouse.
Children.
-- Martial of Negatlva
X Abnormal or Paalthsa
ADDITIONAL HISTORY: Nervous System (Migraine, Convulsions), Blood Pressua, Cardiovascular, Lungs, (Tuber-
culosis,), Gastrointestinal, Genitourinary, Hematologic (Bleeding), EndocEjnJ J ^^^g)", Tumors, Psychiatric
PnnCirornflL FOREST HOSPITAL SPUI I RR" CHRISTUM
LUlinytliliriES PLAINES, ILLINOIS *, -4 ?
INITIAL TREATMENT PLAN
(To be completed within 72 hours of admission) >R
!U
PATI E
DATE
DATE OF ADMI SSI ON: M\)~^ j 4 ^
PHYSI CI AN:
N
I ONAL DI AGNOSI S' ] * PROVI SI ONAL DI AGNOSI
AXI S I
Secondar y
AXI S I I
/ , / AS j / i . i i
J USTI FI CATI ON. FOR HOSPI TALI ZATI
\
fa&M ^ r^MMrtyi "H^ fin*
V>
CURRENT EMOTI ONAL AND BEHAVI ORAL DESCRI PTI ON
DI SCHARGE CRI TE
ANTI CI PATED A F WR C ME PLAN: / ) ,
few gj^
FOREST H
r
"PI TA L
DES PLAI NES I L L I NOI S
MASTER COMPREHENSIVE TREATMENT PLAN
PROBLEM LI ST
05 U9 <*
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THE DST I S SAI D TO HAVE AN OVERALL SENSI TI VI TY OF 67%AND f t
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FALSE HI GH VALUES MAY BE CAUSED BY STRESS, CERTAI N DRUGS,
ENDOCRI NE DI SEASE, HI GH ESTROGEN LEVELS OR MALNUTRI TI ON.
FALSE LOWVALUES MAY BE CAUSED BY HYPERCORTI SOLI SM, STEROI D
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I I . Pat i ent Teachi ng: ( Ci r cl e " yes" or " N/ A" as appr opr i at e. I f "Yes'
not ci r cl ed f or appl i cabl e i nf or mat i on, a comment i s r equi r ed) .
Pat i ent or r esponsi bl e
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Comment s
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Act i vi t y:
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Di sposi t i on of Bel ongi ngs
/UL^JS
Val uabl es
Pat i ent ' s Per sonal Medi cat i on ( Physi ci an' s or der obt ai ned) / Yes ) No
I dent i f y Medi cat i ons: rzJ
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Pat i ent / Si gni f i cant Ot her Consent Obt ai ned
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Ti me :
Yes No
Da t e :
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Ti me: oJ/P\j Mode: ^- T ^- ^^C ^X A ^ Accompanied By:
Q. & A. Compl et ed: / Yej
Basi s 32B Compl et ed:
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Si gnat ur e of R. N. Res
RN1- 52, Apr i l , , 1
: / Ti me (g il-Hi
3 PM
FOREST HOSPI TAL
DES PLAI NES, I LLI NOI S
VI SUAL SCREENI NG
Dat e Request ed:
Dat e Compl et ed:
^ >f e^ -
ACUITY
jiROEnm
CORNEAL REFLEX
PUPI LLARY RESPONSE
TRACKI NG
COVER TEST
STEREOTEST
COMMENTS:
SP1ZZI RRI *
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BOTH EYES
D-o
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LEFT
RIGHT
20/ ^o
20/ ^o
REVI EWED BY ATTENDI NG PHYSI CI AN' .
Si gnat ur e:
Eval uat or
REFERRAL NEEDED: YES_
NO
Si gnat ur e:
Cteti &f og Physi ci an
Whi t e: Char t
Yel l ow: School
l mb: 6/ 87