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INITIAL ASSESSMENT AND EVALUATION
What To Expect
• Seeking medical help is the first important step in the care
process. During the first meeting, a health care professional
will review how the patient is doing. This assessment is geared
towards learning as much as possible about the patient. This
information will help develop a treatment plan that best matches
the patient's individual needs.
• The assessment will cover things like:
» A patient's goals and preferences for treatment
» Current and past symptoms, including risk to self or others
» Use of tobacco, alcohol, or any other substances
» Treatment history and any medications currently or recently taken
» Current physical and mental health status
» Any past trauma – physical, sexual, or emotional
» Details such as housing, schooling, finances, occupations, and
relationships
» Medical information and testing:
▶ Vital signs (pulse, blood pressure, temperature)
▶ Body weight and height
▶ Blood tests to look for high cholesterol or diabetes
▶ Pregnancy screening
▶ Toxicology screen
▶ Imaging (CT, MRI, or other)
▶ Heart monitoring (ECG)
• Discussions with patients, family members, and/or others in
the support network will also typically occur as part of the
initial evaluation. Additional input will be needed as treatment
proceeds and the treatment plan is updated.
• Every person's situation is different and, after the assessment,
the healthcare clinician will discuss all recommended treatment
options. Choosing the best options will be a shared decision
between the patient and the clinician, often with input from
family members or others in the person's support network.
