Sample Clinical Assessment Report
SAMPLE CLINICAL ASSESSMENT REPORT
identification data
Name : Johan Dollah
Age : 35
Date of birth : 16 February 1976.
Sex : Male
Race : Malay
Education : Degree in Computer Science, Australia
Occupation : Computer programmer at NEXIS Communications
Marital Status : Married with three children
pROBLEM
Chief Complaint Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking sensations. Those panic symptoms would often last for one to two hours or until he removed himself from the anxiety provoking situation.
Reason for Referral The patient was referred for psychotherapy to control his panic symptoms.
History of Presenting Illness The patient began feeling conscious of people around him when he was around 17. Before that, he was not concerned with what people thought of him. He could not explain the cause for the gradual change in behaviour. When younger, he would often climb trees and swim in rivers without fear of endangering himself. However, as he turned 17, he began to fear accidents and the injuries that they might cause. He was unable to recall any significant event in his life that might have influenced his condition.
He said that he had no severe feelings of anxiety when he was studying in Australia. There were occasional feelings of nervousness when he had to do class presentation, but he described those reactions as normal and he was able to overcome them. It was only when he returned home to Malaysia and started working when he began to develop those strong feelings of anxiety when he had to deal with his colleagues. He would always try to avoid any
identification data
Name : Johan Dollah
Age : 35
Date of birth : 16 February 1976.
Sex : Male
Race : Malay
Education : Degree in Computer Science, Australia
Occupation : Computer programmer at NEXIS Communications
Marital Status : Married with three children
pROBLEM
Chief Complaint Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking sensations. Those panic symptoms would often last for one to two hours or until he removed himself from the anxiety provoking situation.
Reason for Referral The patient was referred for psychotherapy to control his panic symptoms.
History of Presenting Illness The patient began feeling conscious of people around him when he was around 17. Before that, he was not concerned with what people thought of him. He could not explain the cause for the gradual change in behaviour. When younger, he would often climb trees and swim in rivers without fear of endangering himself. However, as he turned 17, he began to fear accidents and the injuries that they might cause. He was unable to recall any significant event in his life that might have influenced his condition.
He said that he had no severe feelings of anxiety when he was studying in Australia. There were occasional feelings of nervousness when he had to do class presentation, but he described those reactions as normal and he was able to overcome them. It was only when he returned home to Malaysia and started working when he began to develop those strong feelings of anxiety when he had to deal with his colleagues. He would always try to avoid any