|
Arrived by self?
|
|
|
Accompanied by Mother?
|
Accompanied by Father?
|
|
Accompanied by Guardian?
|
Accompanied by Other (Free Text)
|
|
Vital Signs Height (in inches)
|
Weight (lbs):
|
|
RR
|
P
|
|
HP
|
Other
|
|
|
|
|
CHIEF COMPLAINT: (free text)
|
|
|
Allergies (No Change)
|
Allergies (changes free text)
|
|
All systems unchanged
|
|
|
General Changes (NONE)
|
General Changes (Yes): Free Text
|
|
Integumentary Changes (NONE)
|
Integumentary Changes (Yes): Free Text
|
|
HEENT Changes (NONE)
|
HEENT Changes (Yes): Free Text
|
|
Respiratory changes (NONE)
|
Respiratory Changes (Yes): Free Text
|
|
Cardiovascular Changes (NONE)
|
Cardiovascular Changes (Yes): Free Text
|
|
Gastrointestinal Changes (NONE)
|
Gastrointestinal Changes (Yes): Free Text
|
|
Genitourinary Changes (NONE)
|
Genitourinary Changes (Yes): Free Text
|
|
Neurological Changes (NONE)
|
Neurological Changes (Yes): Free Text
|
|
Skeletal Changes (NONE)
|
Skeletal Changes (Yes): Free Text
|
|
Endocrine Changes (NONE)
|
Endocrine Changes (Yes): Free Text
|
|
Lynphatic Changes (NONE)
|
Lymphatic Changes (Yes): Free Text
|
|
|
Other Changes (Yes): Free Text
|
|
|
|
|
Review of History (NO CHANGES AT ALL)
|
|
|
Medication Changes (NONE)
|
Medication changes (FREE TEXT)
|
|
Patient Medical History Changes (NONE)
|
Patient Medical History Changes (FREE TEXT)
|
|
Patient Psychiatric/Mental Health Changes (NONE)
|
Patient Psychiatric / Mental Health Change (FREE
|
|
Family Psychiatric/Mental Health Changes (NONE)
|
FamilyPsychiatric / Mental Health Change (FREE
|
|
Family Medical Changes (NONE)
|
Family Medical History Change (FREE
|
|
Psychosocial/Academic History Changes (NONE)
|
Psychosocial/Academic History Changes (FREE
|
|
|
|
|
MSE: Unchanged in all areas OX4)
|
|
|
MSE: General (cooperative)
|
MSE: General (other FREE TEXT)
|
|
Eye Contact (appropriate)
|
Eye Contact (other FREE TEXT)
|
|
Body Type (average)
|
Body Type (other FREE TEXT)
|
|
Posture (No abnormality)
|
Posture: (other FREE TEXT)
|
|
Gait (appropriate)
|
Gait:(other FREE TEXT)
|
|
Coordination: (Normal)
|
Coordination: (other FREE TEXT)
|
|
Motor Activity: (WNL)
|
Motor Activity: General (other FREE TEXT)
|
|
Reliability: (Intact)
|
Reliability: General (other FREE TEXT)
|
|
Sleep Pattern (Restful)
|
Sleep Pattern: General (other FREE TEXT)
|
|
Delusions (Denied)
|
Delusions: General (other FREE TEXT)
|
|
Obsessions (Denied)
|
Obsessions: General (other FREE TEXT)
|
|
Compulsions (Denied)
|
Compulsions: General (other FREE TEXT)
|
|
Suicidal Thoughts (Yes = DENIED; No = Active)
|
|
|
SI Thoughts (Yes = Fleeting; No = Passive)
|
SI Description or Other (other FREE TEXT)
|
|
|
|
|
Homicidal Thoughts (Yes = DENIED; No = Active)
|
HI Description or Other (other FREE TEXT)
|
|
Homicidal Thought (Yes = Fleeting; No = Passive)
|
|
|
Speech Pattern: (WNL)
|
Speech Pattern: (other FREE TEXT)
|
|
Fund of Knowledge (Average)
|
Fund of Knowldege: (other FREE TEXT)
|
|
Abstraction (appropriate)
|
Abstraction: (other FREE TEXT)
|
|
Attention: (appropriate)
|
Attention: (other FREE TEXT)
|
|
Judgement (WNL)
|
Judgement: (other FREE TEXT)
|
|
Memory: (Intact)
|
Memory: (other FREE TEXT)
|
|
Mood: (Euthymic)
|
Mood: (other FREE TEXT)
|
|
Affect: (Congruent)
|
Affect: (other FREE TEXT)
|
|
Thought Processes (Logical)
|
Thought Processes: (other FREE TEXT)
|
|
Hallucinations (Denied)
|
Hallucinations: (other FREE TEXT)
|
|
Dissociative SXs: (Denied)
|
Dissociative SX:(other FREE TEXT)
|
|
Phobia(s): (Denied)
|
Phobias: (other FREE TEXT)
|
|
Other: (None)
|
Other: (other FREE TEXT)
|
|
|
|
|
Diagnosis: Working Diagnosis
|
|
|
Diagnosis: Axis I
|
|
|
Axis II
|
|
|
Axis III:
|
|
|
Axis IV: (choose one or more)
• • •
|
|
|
Axis V:
|
|
|
|
|
|
Possible Treatment Options (#1 FREE TEXT)
|
|
|
#2 (FREE TEXT)
|
|
|
#3 (FREE TEXT)
|
|
|
#4 (FREE TEXT)
|
|
|
#5 (FREE TEXT)
|
|
|
|
|
|
Formulation & Chosen Plan: (FREE TEXT)
|
|
|
|
|
|
Medications Ordered: (FREE TEXT)
|
|
|
#2 (FREE TEXT)
|
|
|
#3 (FREE TEXT)
|
|
|
#4 (FREE TEXT)
|
|
|
#5 (FREE TEXT)
|
|
|
|
|
|
Labs Ordered: (FREE TEXT)
|
|
|
|
|
|
Referrals: (FREE TEXT)
|
|
|
|
|
|
Therapy Add Ons: (CHOOSE MULTIPLE)
• • •
|
Therapy Focused On (CHOOSE MULTIPLE)
• • •
|
|
Reviewed risks w/ Client (yes) / Caregv& Client
|
|
|
Reviewed treatments recommended & off label
|
|
|
Safety Risk Assessment: (No threat / Yes threat)
|
|
|
|
|
|
McKay Signature Line (must still sign it)
|
|
