PSYCHIATRY DEPARTMENT
NAVAL OPERATIONAL MEDICINE INSTITUTE
220 HOVEY ROAD
PENSACOLA, FL 32508-1047
Name: Date of Evaluation:
SSN: Command:
Source of Referral:
Identifying Information: This was the first NOMI psychiatric evaluation for this ?year old ?single ?Caucasian ?male /?USN, with ?y ?mo CAD(BAD) who is currently stationed at . He was referred for psychiatric evaluation by for the purpose of . Before the interview commenced, CAPT Wear-Finkle informed the member of the purpose, nature, and possible consequences of the evaluation. The patient signed the Privacy Act Statement at the beginning of the mental health questionnaire and freely consented to this interview. SECNAVINST 6320.24 (Boxer Law) did not apply as the member was referred by. . . CAPT Wear-Finkle also explained confidentiality issues and limits. The member’s medical record, service record, and questionnaire were reviewed prior to the interview. Present at the interview were. . . . .
History of Present Illness: The member reported that he was in his usual state of ? health until...... TELL THE STORY. . . .(Include all relevant psychiatric symptoms – both an appropriate positive and negative ROS - and any previous psychiatric treatment)
SH: He was the ?eldest of ?sibs from an ?intact ? home. He reported a happy childhood and had many friends in school. He denied any problems in school, always doing well. He described his father, a , as “ .” He described his mother, who is a , as “ .” He participated in several sports in high school including. . . ? motivation to fly? Include any FH of psychiatric disease here. (Include work history, legal history, military history, relationship history, etc. Add anything that provides pertinent information about this individual)
PMH: His medical history is significant for . He does not use tobacco products and drinks two caffeinated beverages per day. He is on no medication and has no allergies.
MSE: [A good MSE should paint a 3-D picture for the reader] He was a well developed (thin, short, ?) well groomed (mildly disheveled, wearing civvies, ?) male who was cooperative (reticent, defensive, openly hostile) during the interview and maintained good eye contact (avoided direct eye contact, ?). His speech was normal (soft-spoken, loud) and motor activity was unremarkable (was increased as demonstrated as being fidgety, was decreased as evidenced by slumping in chair and not shifting position, ?). He described his mood as, “pretty good,” and displayed an affect that was full ranging (constricted, blunted, flat, ?) and appropriate (inappropriate) to expressed thought content. His thought processes were logical (illogical - as manifested by. . . .), coherent (difficult to understand, incoherent), and goal directed (meandering, no apparent focus, ?). His thought content was negative (?/+) for suicidal, homicidal, and paranoid ideations (both past and current). He denied hallucinations and there were no apparent delusions. His cognition, although not formally tested, was grossly unimpaired. Intelligence was estimated to be above/below average. His judgment was good (excellent, poor, ?). His insight was fair (?), and his impulse control was unimpaired (impaired) based on his history of. . .
Formal psychological testing including a NEO-PI-R was performed and revealed:
Summary/Conclusion: Put the significant data to support your diagnoses on Axis I and Axis II, and any clarification so your reasoning is understood.
Diagnoses:
Axis I:
Axis II:
Axis III:
Recommendations:
1. The member is presently psychiatrically Physically Qualified (NPQ?) and Aeronautically Adaptable (NAA?) for duty as a Student Navigator (?). He is presently psychiatrically fit (unfit?) and suitable (unsuitable?) for general duty. (He is aware of and accountable for his actions).
2. Suicide risk is felt to be negligible. . .
3. The results of this evaluation were discussed with the member, his flight surgeon, etc.
4. Although no formal psychiatric f/u is required, . . . . .
5. Please contact me at 452-4238 for any questions/clarifications.
6. ETC.
D. J. WEAR-FINKLE
CAPT MC USN
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