Body Image Disturbance

 

Instructions: Fill out this form, print it, and hand it in with your assessment to your instructor. When you click on Next at the bottom of the page, you see the data you submitted. Please follow the instructions on how to save the data on the next page.

AOL users: Read this instruction.

Definition:confusion about or disruption of mental picture of one's physical self

1. Your initials (required): 

2. Defining Characteristics- check those that apply to your client:

None- high risk diagnosis  verbal negative response to actual or perceived change in structure or function
non verbal negative response to actual or perceived change in structure or function not looking at body part
fear of rejection by others  preoccupation with change or loss change in social involvement
3. Related Factors- check those that apply to your client:

loss of body part chronic disease loss of body function severe trauma surgery radiation pregnancy aging


4. Goal (ultimate, long term) 

5. Outcome Criteria (short term) 

6. Evaluation: Was the outcome criteria met? 

Yes- Give Evidence: 

No- Explain how you would change the plan: 

7A. Interventions 

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7B. Rationale for each intervention
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