Running head: Biopsychosocial assessment 1

Biopsychosocial
Kelly E. Burg
Wayne State University

Biopsychosocial assessment 2
History to Include/ Presenting Problem
Tina Smith is a 54 year old single Caucasian female, who is divorced. She has been
divorced for twelve years, but continues to still have problems with her ex-husband concerning
their children. Tina currently lives with her daughter (female 22 years old). She has been
employed as a florist designer for eleven years. Tina is extremely stressed out from work because
she doesnt get paid on time like she is supposed to. Tinas bills are always late and she has no
choice but to remain at the job because she has no college education. Tina is coming to see a
Social Worker because she is stressed out with her work and she is facing issues with her exhusband concerning children.
Family Origin History
Tinas mother and father were married when Tina was born. Tinas mother Irene was 30
years old when she was born and Tinas father Earnest was 33 years old. She has three older
brothers. Daniel who is 64 years old, single, and is a professor is her oldest brother. Timothy is
61 years old, married, and is the ATT Union President. Randal is 59 years old, single, and a
Radiologist. Irenes pregnancies were all planned. Irene and Earnest remained married 43 years
and raised all of their children. Earnest passed away at age 65 with the cause of a brain aneurism.
Irene is still living and is currently 86 years old.
When growing up Tina describes her home life as a perfect environment. The house hold
was very clean and she had great parenting growing up. The holidays were always celebrate as a
family gathering for Christmas and Easter. They would start off with dinner and socializing. At
the end they played games and passed out presents to one another.
Irene and Earnest completed high school, but did not attend college. Tina and Timothy
both did not attend college. Randal attended a radiology program for two years. Daniel was the

Biopsychosocial assessment 3
only one that attended college. He received three Bachelor Degrees and three Master Degrees.
All of the siblings are in good health besides Randall. Randall recently got diagnosed with
Parkinsons disease. Irene is good in overall health, she currently has a small issue with her heart.
Nothing too serious. Irene survived breast cancer two times. When Earnest passed away, the
whole family was shocked because it was unexpected. This caused them to have issues mourning
because they couldnt get over that he passed away so young.
Developmental History
Irene went the full term of 9 months when Tina was born. She was 5 pounds and two
ounces. Tina was a vaginal delivery. There were no issues when she was born. Tina was bottle
fed because Irene previously had breast cancer. She weaned off the bottle at age two. At 15
months Tina began to walk and talk. Tina also was toilet trained at age 2. There were no
developmental delays.
Health History
Tina had no health problems and no surgeries growing up. At age seventeen Tina began to
get chronic hives that lasted until menopause. She was very allergic to mold and was put on
steroids to help with them. Her first and only accident was at age 18, Tina hurt her head and her
arm, and she was hospitalized for two days. In Tinas adulthood she has not had any health
problems or surgeries. Tinas mother has survived breast cancer two times and Polio one time.
She currently has heart disease. Tina was eleven years old when she received her first menstrual
cycle. She started menopause at age 50. Tina is on no medications and isnt allergic to any
medications.
Relationship/Sexual History

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Growing up Tina had great childhood friends. She currently keeps in touch with five of
them through phone and Facebook. Tina has great friends currently, she is a very sociable and
likable person. One of her friendships have lasted for 41 years and she still is friends her. Tina is
straight is single. At age 15 she had her first boyfriend. At age 19 she had her first sexual
experience. Tina is still able to enjoy orgasms, but is currently not in a sexual relationship. Tina
uses no protection or birth control because she is not having sexual relationships with anyone.
Family of Creation History
Tina got married at age 23 to James who was 25 years old. Tina and James decided to get
married because they had been dating for about four years and wanted children. They have two
children together, Jackie who is female and 23 years old and Kyle who is male and is 26 years
old. At age 42 Tina and James got divorced because James cheated on her. Tina did not attended
college, but James attended the University of Wyoming and received a business degree. Jackie
and Kyle both work for their fathers company.
Kyle was an accident and Jackie was planned. They were both vaginal deliveries. Tina
and James wanted to have children because both of them had siblings who had children and they
wanted one of their own. Tinas relationships with her children are great. Tinas relationship with
James is very difficult concerning problems with their children.
Substance Use/Abuse History
Tina has no substance abuse history. Tina is a casual social drinker when she goes out
with friends. At age 14 she had her first sip of alcohol. When she goes out she only has about
three glasses of wine.

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Mental Health History
After Tinas divorce, she was in a state of depression. She went to therapy for about six
weeks, but found that it was not helpful in anyway. She went to therapy in Shelby Twp., MI. Her
therapist prescribed her Zoloft, she only took the medication for about four weeks and began to
think about suicide often. Tina then took herself off the medication.
Military Experience
Tina has no military experience.
Financial History
Growing up Tina grew up in an average household and was considered Middle-Class.
When Tina got married, James had a lot of money, she classified herself as rich and Upper-Class.
After Tina and James got divorced, Tina went to Middle-Class, where she currently describes
herself as average. If Tina was paid regularly from her job, she would have no issues paying bills
or any money problems.
Legal History
Tina has no legal history.
Immigration History
Tina has no immigration history.