584 ●^ APPENDIX H
Date^ Client’s Name^Age^
Marital Status^ Children^
Occupation^ Presenting Symptoms (subjective & objective)^
Diagnosis (DSM-IV-TR)^ Current Vital Signs: Blood Pressure: Sitting / ; Standing /; Pulse ; Respirations
CURRENT/PAST USE OF PRESCRIPTION DRUGS (Indicate with “c” or “p” beside name of drug whether current or past use): Name Dosage How Long Used Why PrescribedBy Whom Side Effects/Results
2 2506_Appendix_H_583-587.indd 584 506 _AppendixH 583 - 587 .indd 584 10/1/10 9:31:01 AM 10 / 1 / 10 9 : 31 : 01 AM