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MEDICAL SUMMARY REPORT----SAMPLE---SAMPLE---SAMPLE Personal History
Joe is a 32 year-old, white male. Joe has been using methamphetamine for the past eight years, smoking the drug 3-6 per week. He is the middle of three siblings. He has an older sister and a younger brother. Joe was born and raised in Arkansas. He moved to the West Coast at the age of 20. He was thrown out of the family home after getting to a confrontation with his brother. Joe said he was abused at a young age but did not want to elaborate on the kind of abuse he suffered. From time to time, Joe said he gets angry at the slight inconvenience which cause him go into rants and outbursts which last for 5 – 10 minutes at a time. He said this started happening right before he became a teenage and occurred ever since. He said these outbursts have caused a strained on many of the relationships he had developed over his lifetime. They have caused him to be suspended from school, lose jobs, be homeless, and destroyed other personal relationships. As a result, Joe said he has only two friends, Bob and Lisa, who are neighbors who live close to him. Physical Health
Joe appears older than his stated age. He has had open sores on various parts of his body in the past because he has not always bathed regularly. However, now he seems to be taking care of himself and was dressed relatively well for the setting. He was cooperative in the interview answering all questions politely. Although today, his memory showed slight signs of impairment. His mood was both anxious and Drug History and Current Pattern of Use
Joe said he first began experimenting with drugs at the age of 12. He drank alcohol every weekend and smoked marijuana on an almost daily basis throughout his teens. At 20 Joe told me he began drinking heavily and experimenting with Ecstasy. At 24, he was introduced to methamphetamine that became his sole drug of choice, in addition to having an occasional drink. He said he would smoke it 3-6 times a week. However, over the last 5 years he has been trying to stop his drug use by and has checked himself into drug rehab several times. Although he has done this, he has not managed to stay clean consistently. During his clean times when he has not done methamphetamine, Joe has smoked cigarettes to cope with his struggle. Substance Abuse Treatment History
When he first started out, he was in recovery at a center in California for about a month five years ago. Once after being arrested in New Jersey for possession of methamphetamine, he entered a local detox center. At that time, he successful y completed its twenty-one day Rehabilitation Program. He did not follow up with aftercare or NA meetings. After testing positive for methamphetamine at probation, Joe was admitted to another detox facility for five days. He must complete an Intensive Outpatient Program or he will face a three-year prison term. Medical History and Treatment
When he was young, shortly after turning age 13, he was hospitalized at the University of Arkansas Medical Center and diagnosed with a bipolar disorder due to one of having an outburst with a total stranger on the street. Usual y, when this has occurred in the past the situation has been de-escalated without any further action being taken. As well to assist with treatment, Joe was prescribed a daily Three years later, Joe has a lapse because he felt he no longer needed to take his medication and was readmitted to the University of American Medical Center after getting to a physical fight with his sister. He broke her col ar bone and was on the verge of doing much more harm to her. Several weeks after this incident, Joe was discharged but while there was given lithium and again 50mg of Cymbalta for Joe has been hospitalized on occasion over the last 17 years when Joe has not taken his medication or when a situation becomes really overwhelming. FUNCTIONAL HISTORY
Family History and Current Relationships
Joe was raised in a two parent household in rural Arkansas. The family was Catholic of Irish and Scottish descent. Today he was wil ing to talk about his abuse and advised his father was an alcoholic and abused everyone in the household both physical y and verbal y. The family was upper middle class. His father was a car salesman. His mother was a dietician. Both parents are deceased. Joe was estranged from his father from the age of 20. He maintained periodic phone contact with his mother until her death three years ago. His father, brother, and sister stopped speaking to him after having one his outbursts. Joe had a girlfriend but she left as well for the same reason. In addition, the relationship was strained as well due to Joe’s drug use and infidelity. Positive Support Systems
Joe’s friends, Bob and Lisa are both drug free and supportive of him seeking treatment. Joe recently began attending services at church. He has made a few friends there and states that the Pastor has been a great support to him. The Pastor has asked him to join the church’s homeless outreach program. Crime and Delinquency
Joe was arrested for being drunk and disorderly on two separate occasions in California. Both times he was fined $500. He was arrested for possession of methamphetamine in New Jersey several months ago and placed on probation. Joe has tested positive for methamphetamine twice since being placed on probation. If he does not enrol in and complete an Intensive Outpatient Program he is facing up to three years in prison. Education
Joe is a high school graduate. He briefly attended a community col ege but dropped out after two semesters. He appears to be of above average intelligence. He reports being an A/B student in high school. Employment
Joe is currently unemployed. In the past he has worked mainly as a waiter and/or bartender. His longest
place of employment started in 2007 at a restaurant in California. He worked there for two years.
However, over the past seven years Joe has been fired from ten different places of employment for
excessive outbursts and once for stealing. He said that most of these places were at nuisance bars but
stil believed this would happen anywhere he worked because of his past altercations. Last year, Joe’s
lost his job because he refused to listen to his employer and continued to things on his terms. This lead
to a confrontation and was seen as insubordinate behavior by his employer.
Diagnosis
Joe’s affect was appropriate to content; he was not overly emotional but reasonably distressed over his current situation. His rate of speech was somewhat rapid when addressing stressful subjects, but otherwise normal. His tone was average throughout the interview. His thought processes were logical; yet he did not consistently demonstrate proper insight as to his own actions and how they contributed to his situation. He denied any current hal ucinations; however, he admitted to smelling something burning and hearing police sirens but after asking others realized they didn’t exist. This has usual y happened when he been under the influence of methamphetamine.

Source: http://www.mhaac.net/Files/Admin/Step8MedicalSummarySample.pdf

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