Form A: Diagnosis Sample

Patient Name: Caulfield, Holden Diagnosing Physician: Weiler, Eric Date: April 3, 1949
Holden Caulfield, 17, is a unique patient of mine with a unique case. In a way he is just like most kids, and yet at the same time he is completely different. During Holdens evaluation, I took note that he has shown a number of emotional and mental conditions/symptoms. The most prominent of all is his varying depression. He is constantly feeling lonely and is desperate for someone to talk to. On one occasion he even goes so far as to commission a prostitute just to talk to her. Holden has a very negative outlook on life, he is a very judgmental person, always noticing the flaws in people and pointing out their phony-ness and often feels as if the whole world were wrong and he was just horribly misunderstood. Also, Holden has a constantly shifting mood that ranges from being very sad to very happy at times that may not seem appropriate. He makes rash decisions during times of extreme stress and then later changes his mind about his them. Holden may be suffering from ADD. He has difficulty paying attention to important things. This may be a cause for his flunking out of school due to failure in almost all of his classes. He mentioned once receiving an important lecture from one of his teachers, and instead of listening, he pondered aimlessly about the location of the ducks at a pond during the winter. Once he even mentioned talking to his brother even though his brother is dead. This hallucination may be a sign of schizophrenia. Holden is also a bit suicidal; during his evaluation I noted the surprisingly low amount of caution he took for his own life. Apart from his mental and emotional symptoms, Holden has shown a number of physical symptoms too. Holden may be a victim of insomnia; he goes to bed long past midnight and then wakes up relatively early, leaving his mind with only a few hours to rest. This lack of sleep is extremely unhealthy for him and is a very likely cause for his current mental and emotional conditions. He does not eat much either, only two or three times during his evaluation did he even mention

Patient Signature: _________________ Referring Physician: _________________

Parent/Guardian: _________________

Form B: Treatment Recommendations

Patient Name: Caulfield, Holden Diagnosing Physician: Weiler, Eric Date: April 3, 1949
In light of the fact that Holden may very well be suffering from these conditions due to his lack of sleep, my number one recommendation for Holden is to, simply, get a good night sleep. In order to do this he should at least receive a full eight hours of sleep and should try for ten if possible. He should consume no stimulants before bed and that includes cigarettes and alcohol. It is likely that Holden may have some difficulty falling to sleep. If that is the case, Holden might want to try drinking some chamomile tea and milk before bed for both of these contain chemicals that promote a restful sleep. My second suggestion to Holden would be for him to completely stop the usage of cigarettes and alcohol. Cigarettes and Alcohol both damage the body in many ways including the nervous system. And since Holden is much younger than the legal limit for both of these substances the impacts are much greater. Stopping the usage of Cigarettes and Alcohol will do Holdens body and mind much good for both now and the future. Also, I would suggest that Holden starts eating more. His lack of eating is very unhealthy and his body is not getting the nutrition that it requires. Since his current habit is to eat very little I simply want him to eat more and, if it is possible, eat healthier too. He should be eating fruits every day and skip no meals. I also dont want him to eat meals too far apart from each other. He should be receiving a healthy supplement of grains, proteins, fruits, vegetables and dairy products. And my final suggestion is for Holden to get involved with some extra curricular activities. His life seems pretty empty with not much purpose. Joining a group will help him with socializing and being less of a lonely person which may help Holden feel less depressed. I am aware that Holden does not get along very

Patient Signature: _________________ Referring Physician: _________________

Parent/Guardian: _________________

Form C: Excerpts from Patient Journal

Patient Name: Caulfield, Holden Diagnosing Physician: Weiler, Eric Date: April 3, 1949
Today I visited the goddam psychotherapist for my goddam evaluation and therapy. I didnt really want to go but I did it because my parents thought that it would be good for me. And so I did. The first thing that I noticed when I came into the office was that some corny old classical music was playing in the background. For some reason it depressed the hell outta me. I mean, I dont hate classical music or anything, in any other place it would be fine, it just made me feel like I was in some kind of mental facility where they played classical music to calm the minds of the guys who were mental. I signed in at the front desk and then sat down. I waited for about ten hours before my name was finally called. Caulfield, Holden. Some guy finally said. Yes? Right this way, sir. The guy led me into his office and made me lie down on one of those beds that you see in the movies when a crazy guy is being evaluated. He introduced himself and then immediately started writing things down on his notepad. The name of my psychotherapist was this old geezer named Eric Weiler. Weiler asked me to tell him about my life so I told him about the last three days of my life. I know Im not crazy. But I thought it was funny, me being crazy and all. I sorta felt like I was in the movies and even pretended I was for a while. The whole time I talked he just kept nodding his head and writing down notes on his goddam notepad, occasionally saying things like really? or is that so? He was a real phony. Then when I finished my little speech I asked him what my results were. He didnt answer, the bastard, he just kept writing down on his little notepad. Finally he handed me my results and then left. I didnt really feel like reading the results