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
He developed initial insomnia, but suffered no loss of appetite or libido. He was frequently taking medical leave to avoid work.

past psychiatric and medical history Mr Johan has no past psychiatric or medical history.

sociodemographic data
Family History

Father Mother 65 y.o. 59 y.o.
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42 y.o. 40 y.o. 38 y.o. 35 y.o. 34 y.o. 27 y.o. Lecturer Housewife Teacher Patient Bank teller Unemployed

Father Mr Johan’s father was a former clerk in the Department of Works. After he retired he worked as a gardener as he was very fond of gardening and also in order to pass his time.

He described his father as a confident but distant person. He did not care even if his children misbehave, and therefore, he was neither harsh nor punitive toward them. He was emotionally distant from all his children as he hardly spoke nor interacts with any of them. He was usually out of the house most of the time. The patient said that it actually made no difference whether his father was at home or not because he would only keep to himself in the house. Since he has never had any much interaction with his father as a child, he hardly talks to his father even until now.

Mother The