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[RAYMOND 8. DEAN & RICHARD W. WOODCOCK Name = wi = Soc Mae @ Fondo Dateof Bh keaton Ccespation Sausean 1 rai “This interview assesses the presence and severity of psychiatric signs and/or symptoms for a subject. Ie may be administered cither ditectly toa subject or to an informant —a parent, caregiver, or someone else who knows the subject well Select the ‘phrasing that is appropriate for the person answering the questions. fa subject is being interviewed directly, read the question as icis writen, Ifan informant is being interviewed, modify the wording accordingly. For example, replace the word you (eg., Do you) with the subjects name (ef, Does Mary). The Spanish wording and directions for this measure ate in Appendix D of the ‘Dean-Woodcock Examiner's Manual. During the clinical interview, ask the subject or informant about each of the symptoms listed. Say: Tam going to ask you about some behaviors or problems that you (your child, your ‘may have experienced. Tell me if each is true for you (your child, your ‘now or recently by responding, “Yes” or “No.” In cases where the subject or informant responds, “Yes” to a sign of symptom, ask him or het: Does this occur Infrequently, Frequently, or Very Frequently? Infrequently Very little of the time Frequently From time to time Very Frequently Most of the time For some signs or symptoms to which the subject or informant responds, “Yes,” ie may also be useful to obtain additional information regarding severity. Say: Hfone is the least severe and ten is the most severe, where do you (does name) fall on this scale? Record 1-10 in the Severity column, 14 Mild Low intensity, resulting in minor impairment of occupational, social, of interpersonal functioning 57 Moderate Berween mild and severe intensity, resulting in moderate impairment of occupational, social, or interpersonal functioning 810 Severe High intensity, resulting in marked impaitment of occupational, social, or interpersonal functioning, For some signs andlor symptoms, the rating may differ from day to day or week to week. Some symptoms are subjective and ‘require the subjects or informant’s opinion to determine a rating, g 2360s PF Riverside Publishing copyratic 2008 oy the riverside Pushing Company A hts eared MCR Oanuirrisccuri? 128507 8990-B0N G00" 08050403 ins UsA te We ors is orc, FV at 110 Soa coo, 0 19, Free Floating Anxiety Do you feel like something is wrong but are not sure what? No | Yes vy] 20, Racing Thoughts Do you have periods when your thoughts race through your mind much faster than usual? | No | Yes v 21. Pani Anxiety Atacks Do you have spells or attacks where you suddenly feel frightened, nervous, or uneasy? _| No | Yes v 22. Anwiety/Nervousness Do you feel nervous, uptight, or stressed out? No | Yes v 23. Memory Impairment | Do you have problems remembering things? No | Yes v 24, Gastrointestinal Problems ‘Are you bothered by nausea, vomiting, bloating, diarrhea, or constipation? No | Yes v 25. Anger Do you lose your temper or become angry easily? No | Yes v 26. Present Homicidal Thoughts Do you currently have thoughts of killing or hurting someone? No | Yes v 27. Somatic Concerns Do you think about your physical health a lot? No | Yes v 28, Recent Headaches ] Do you often have headaches? No | Yes v 29. Aggressive Behavior : Do you have fights that involve exchanging blows, or hitting others, or verbal aggression? | No | Yes v 30, Problems With the Law Have you had any problems with the law or been arrested for anything other than minor offenses? No | Yes v 31. Alcohol Use Do you drink alcoholic beverages? No | Yes v 32. Drug Use Do you use any recreational drugs (for example, marijuana, uppers, or downers)? No | Yes v 33. Tobacco Use Do you use tobacco? No | Yes vI 34, Sexual Problems Do you have sexual problems? No | Yes v 35. Recent Personality Changes Have you or other people noticed recent changes in your personality? No | Yes v 36. Introversion/Shyness [Are you shy or do you withdraw from others and keep to yourself? No | Yes v 37, Paranoid Thoughts Do you think that people ae spying on you or believe that other people are ploting against you? No | Yes v ‘Comments: - i eae Ly 38. Delusional Thoughts Do you think that someone is reading your mind or do you feel you know the exact ‘words that other people are thinking? No | Yes +39. Hallucinations Have you ever been completely awake and seen, heard, smelled, or felt something that poereeemen ies il ve ‘40. Derealization/Depersonalization Sa ee ee Eee fe Ys 41. Ideas of Reference ee that people talk about you a lot? No | Yes |42. History of Abuse Have you been physically, sexually, or emotionally abused? No | Yes Have you run away from home, tried to run away, or talked about running away? No | Yes ‘4%, Oppositional-Defiant Behavior Saree eee. ie Cae epee ene eras ‘al 46, Planning Ability = ee 47. Confabulation: ] eee Bs Gixiaiones ‘Do you have difficulty feeling emotion? No | Yes | 49. Disinhibition pee ee el a 50. Utilizing Feedback Ff Do you have difficulty changing the way you act, even when it would be beneficial? No | Yes — ee | SPAHTANCLINIOALOBSERVATIONS/ANOAMPRESSIONS aici TABS RS RM During the initial interview and examination, observe the subjects behavior and mood. For each ofthe folowing factors, select the category or rating that best describes your obsereation. More than ‘one feature may be indicated for a given factor. Consult the Dean-Woodcock Examiners Manual fora more detailed description ofeach behavioral feature. A. Orientation, Was the subjece oriented to person, place, time, and situation? D1. Yes, to all four. Q2.No If no, check all that apply as descriptors ofthe subjects disorientation Oa. Person Ob Phace Oc Time O 4. Situation B. Attention, Choose the phrase that best describes the subject's attention level 1, Focused, normal D 2. Necded redirection 3, Distracted easily 1 4. Impaired C. Comprehension. Choose the phrase that best describes the subject’ level of comprehension. 1. Normal G2. Normal with repetition 5. Partial with repetition 4, Impaired with repetition D. Speech. Choose the phrase that best describes the subject's speech patterns. G1. The subject’ speech appeared normal G2, The subject’ speech was not normal. If 2, complete the following. ‘a. Check all that apply as descriptors of the subject’ speech. 1. Accent O 2. Slureed O 3. Labored O 4 Seuttered b. Did the subject have articulation problems? 1. No articulation problems 2. Minor articulation problems O 5. Significanc articulation problems «. Did the subject have word finding problems? Q1.No O 2. Yes E. Consciousness. Choose the term that best describes the subject’ level of consciousness. Stuporous Other The subject’ level of consciousness is best described as E. Grooming. Choose the bese descriptor of the appearance of | the subject’ clothing and manner of dress. D1, Meticulous 2 a3 a4 as. 06. az. Neat, clean Appropriate Casual Disheveled Diry Other ‘The subjects grooming is best described as. G. Age/Appeatance. Choose the best description of the subject's apparent age 1. Appeared younger than reported 12. Appeared reported age 53, Appeared older than reported H. Height, Choose the best description of the subjects height. 1. Above average height G2. Average height G 3. Below average eight 1. Weight, Choose the best description of the subjects weight. a1 a2 a3 a4 as. Very underweight Somewhat underweight Average weight for hei Somewhat overweight Obese ese RSENS SR a J+ Mannerisms. Did the subject display any physical mannerisms | L. Mood. Did the subjects mood appear normal? Byes check al that app a. Seemed to respond to visual hallucinations 1 b. Seemed wo respond to atry hallucinations | Qc, Seemed to respond to tactile hallucinations | Oa Seemed to respond o olfactory hallucinations | Oe Other ‘outside the range of normal behavior? OL Yes ALNo 02.No 02% If no, check all hat apply Hf yes, check all thas apply © a. Depressed O a. Tremors O b. Elevated Ob. Tics | Oc. Euphoric O Rigidity O ad. Irritated Od. Peychomotor retardation O &. Dysphoric Oe. Ataxia OF Hopeless O £ Caaplery Og Apathetic Og, Odd grimacing | Oh. Other Oh. Repetitious speech ‘The subjects mood ean [also] be described as Q ii, Perseveration | Q ji. Fidgery | ae Ok Tearful | OL Poor eye contact | Om. Other | ‘The subject {also} exhibited the following | -M_Affec. Did the subject’ affect appear stable? ‘mannerism(s): foi 7 2No ee i ‘no, check all hat appl | O a Labile Db. Blaneed O Restricted K. Perceptual Disturbances (during interview). Did the subject Od Fle seem to respond to hallucinations? - | Oe Other Q1.No | The subject’ affec can [aso] be described as 02% N. Appropriate Affect. Was the subjects affect appropriate for the subject and setting? ‘The subject [also] seemed to respond ro hallucinations involving OL Yes O2.No If no, check al hat apply. a. The subjects affece was inappropriate for subject 1b. The subjects affect was inappropriate for setting SSS _ PART CLINICAL OBSERVATIONS AND IMPRESSIONS iow oS ©. Anxiety. Choose the best description of the subjects level R. Mental Content, Did the subjects mental content appear to of anxiety bbe nozmal? D1. Relaxed le Give Q 2. Mildly anxious 2.2.No 3, Moderately anxious Ifo, check all shat apply G4, Severely anxious a. Loose associations Ob, Ideas of reference P, Agitation, Did che subject appear agitated? O Thought broadcasting Q1.No Od. Obsessions 02% Q &. Compulsions Ifyes, check all that apply. Qf Homicidal thoughts O a. Tense Og, Incoherent Ob, Fidgery, restless Oh, Persecution Oc. Talked excessively i, Somat Focus Od. Constant motor activity Oj. Delusions Qe. Ocher | O k. Confusion ‘The subject appeared agitated; specifically, he | Q 1. Phobias or she Om. Anger On, Suicidal ideations Oo, Feas | Q p. Derelization | Og, Other {Q Flow of Thought. Did the subject’ low of thought appear to “The subjects mental content [aso] appeared 0 be appropriate? be abnormal because 1. Yes 2.No ‘fn, check all shat apply as descriptors of the subjets | flow of hough. | Oa, Pressured 1 b, Tangential | Oe. Delusional | 5, Task Persistence. Choose the phrase that best describes the O d. Obsessive | subjects persistence with tasks. Q . Confabulations G1. Persistent without prompting Flight of ideas 2, Persistent with prompting Og Circumstantial 5. Atcempred briefly O hi. Incoherent O14. Refused after difficult cask Oi. Blocking 5. Refused Q ji, Racing Qk. Ocher “The subjects flow of thoughs (also) appeared to involve STZ aR ‘T Interaction. Choose the term that best describes the subject’s | U. Insight. Choose the term that best describes the subject’ level style of interaction. | of insight. O 1. Friendly O11. Good O12. Reserved O 2. Fair Q 3. Reluctant O 3. Poor D 4, Cooperative Q 5. Indifferent | V. Judgment. Choose the term that best desribes the subject's O 6. Oppositional | level of judgment. 0 7, Hose, angry f G1, Gooa Q 8. Fearful jf Ooe 9. Guarded | 23. Poor O10. Dramatic O11. Other ‘The subject’ style of interaction is best described as SSS Name : w D Sex Q Male © Female Date of Bith 1 Education Cccupation Date of Emotional Status Bam 4 Examiner This interview assesses the presence and severity of psychiatric signs and/or symptoms for a subject. It may be administered cither directly to a subject or ro an informant—a parent, caregiver, or someone else who knows the subject wel. Select the phrasing that is appropriate for the person answering the questions. IFa subject is being interviewed directly, read the question as itis writen, [Fan informant is being interviewed, modify the wording accordingly. For example, replace the word you (e.g Do ‘you) with the subject's name (e., Does Mary). The Spanish wording and directions for this measure are in Appendix D of the Dean-Woadcock Examiners Manual. During the clinical interview, ask the subject or informant about each of the symptoms listed. Say: I am going to ask you ‘about some-behaviors of problems that you (your child, your ‘may have experienced. Tell me if each is true for you (your child, your ___) now or recently by responding, “Yes” or “No.” Voy « hacerle algunas preguntas sobre la conducta o algunos problemas que usted (su hijo, su_) pudiera haber cexperimentado, Digame si cada una es verdad en su caso (en el caso de su hijo, su___) ya sea ahora o diltimamente, respondiendo “si” 0 “no”. In cases where the subject or informant responds, “Yes” to a sign or symptom, ask him or her: Does this occur Infrequent, Frequently, or Very Frequently? Ocurre esto con poca frecuencia, frecuentemente 0 muy frecuentemente? Infrequently Very little ofthe time Frequently From time to time Very Frequently Most of the time For some signs or symptoms to which the subject or informant responds, “Ys,” it may also be useful ro obtain additional information regarding severity. Say: If one is the least severe and ten is the most severe, where do you (does name) fall on this scale? Record 1-10 in the Severity column, Si en una escala del uno al diez, el uno representa el menor grado y el diez el mayor grado de intensidad de los sintomas, zen qué nimero cae usted (nombre)? 14 Mild Low intensity, resulting in minor impairment of occupational, social, or interpersonal Functioning 5-7 Moderate Between mild and severe intensity, resulting in moderate impairment of occupational, socal, or interpersonal functioning 810 Severe High intensity, resulting in marked impairment of occupational, social, or interpersonal functioning For some signs andlor symptoms, the rating may differ from day to day or week to week. Some symptoms are subjective and require the subject’ or informant’ opinion to determine a rating. ‘ € é € € € € € € € € € é 185 Appendix D = Spanish Version of the Emotional Status Examination Page 1 Emotional Status Examination hel ore is ce ‘at 1-10 Soy car, Mf + 1. Present Depression {Se siente usted en la actualidad deprimido (deprimida), triste o melancblico (melancblica)? Yes 2 History of Depression Se ha sentido usted alguna ver deprimido (deprimida), triste o melancélico (melancslica) durante 2 0 més semanas? 3, Present Suicidal Thoughts ‘Actualmente, zpiensa usted en matarse 0 suicidarse? Yes 4 Hyperactive Moror Behavior Siente usted como que necesita estar constantemente en movimiento 0 como que no puede quedarse quieto (quieta)? Yes 5, Periods of Euphoria ‘Se siente usted a veces tan anormalmente feliz, alegre 0 “euférico” (euférica).al panto que podrla meterse en embrollos o preocupar a otras personas? | Yes 6. Low Energy Level ‘std usted cansado (cansada) la mayor parte del tiempo o siente debilidad muscular? Yes 7. Recent Change in Appetite or Weight Ha cambiado su apetito 0 peso dhtimamente? Yes 8. Recent Sleep Disturbance Le cuesta a usted siltimamente dormirse o se despierta durante la noche 0 demasiado ‘temprano por la mafiana? Yes 9. Self-Deprecatory Thoughts Se siente usted a menudo inservible, pecaminoso (pecaminosa) o culpable? 10. Disuacibilicy Se distrae usted tan fécilmente que pierde a atencién con cualquier pequefia interrupciér?| Yes 1. Inarcention Le cuesta a usted prestar atencién a algo aunque sea por sélo un corto periodo de tiempo? Yes 12. Impulsiviey Acta usted impulsivamente y hace o dice cosas sin pensarlas bien? Yes 113. Poor Concentration Le cuesta a usted aclarar la mente y concentrarse en algo? ‘Yes [74 Confusion ‘Se confunde usted ficilmente porque parece pensar con lentitud o se le meaclan las ideas? Yes 5. Obsessive Thoughts ‘Sele ocurren a usted pensamicntos irracionales,ridiculos 0 repettivos que le resulta imposible parar? Yes 6. Antisocial Behavior ‘Tiene usted antecedentes de iniciar incendios, herit animales, mentit 0 robar? [17. Compulsive Behavior | Hace usted cosas de nuevo una y otra vex aun cuando es innecesario repetirlas (por cjemplo lavarse las manos repetidamente, contar 0 poner las cosas en orden, o verficar que realmente las puertas estén cerradas con llave o que las luces estén apagadas)? Yes WB. Fears/Phobias

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