Classified
Patient's name: Cornelious Hale
Age: 14
Height: 4'2"
Skin Tone: White
Eye Color: Green
Natural Hair Color: Black
Parent's or legal guardian's name: Arcelia Hale
1)# General findings:
A. Physical Abnormalities:
Extremely Pale
B. Vision:
Unclear Vision
More Tests Are Needed!!!
C. Speech and Hearing
• Unclear Hearing,
• Confusing Speech
More Tests Are Needed!!!
2)# Behavioral Problems:
Hyperactive: No
Withdrawn: Yes
Short Attention Span: No
Disturbed Sleep Pattern: No
Distracted: Yes
Other: Shaky hands, unclear thoughts, low confidence and energy, trouble concentrating and possible depression or anxiety.
3)# Specific Findings:
• Neurological Examination shown signs of phycological damage and truama,
• Motor and Sensory Abnormalities varied and had mixed results
More Tests Are Needed!!!
4)# Medical recommendations (including Medication as Prescribed):
Prescribed Clozaril with a starting dose of 12.5 mg once daily or twice daily with or without food until further notice.
Referred Therapist: Howard Moody
5)# Additional Notes:
Patient has described traumatic events causing uneasiness in conversations of certain topics and uneasiness being around needles, described events indicating signs of Post-Traumatic Stress Disorder and Schizophrenia.
Physician's Signature: Savannah Kessler
Date: 7/2/????
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