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Initial Clinical AssessmentClients Name:Date of Birth: Gender: M / Date of Evaluation: Name of Evaluator(s) and License (Please print): Sources of Information: (list names and label, i.e. patient,
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Initial clinical assessment is the first evaluation of a patient's condition to determine treatment needs and develop a care plan.
Medical professionals such as doctors, nurses, and therapists are usually responsible for conducting and documenting initial clinical assessments.
Initial clinical assessments are typically filled out by gathering patient information, conducting physical exams, and documenting findings in a medical record.
The purpose of initial clinical assessment is to gather comprehensive information about a patient's condition to guide treatment decisions and determine the appropriate care plan.
Information such as medical history, current symptoms, vital signs, physical exam findings, and recommended treatment options should be included in an initial clinical assessment.
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