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My Perception of My Family Member's
Current
Functioning
Patient's name: __________________________________________________________
Form completed by:________________________________________________________
Relationship to patient:__________________________________________________
Date: ____________________________________________________________________
Specific concerns I have about my family member:
Have there been any major family or life events that could be affecting
his/her mental health?
Overall, I think my family member's current mental health is: (circle
one)
Better than usual |
About normal
for him/her
in past 2 years
|
A little worse
than usual |
The worst
he/she has been
in in past 2 years |
My impression of patient's:
- Compliance with medications (is he/she taking them as prescribed?):
- Current sleeping habits (# of hours/night, naps):
- Current use of alcohol or other drugs:
- Daily activities:
Questions I have for the doctor:
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