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History
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Chief Complaint
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Turn ON if NEW PATIENT
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Turn ON if EXISTING PATIENT
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HPI (New Patient)
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Update Since Last Encounter (Established Pt)
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Medical History
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Are you pregnant?
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Enter any change to patient history or status below
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Current Medications
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Drug Allergies
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Developmental History
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Social History
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Legal History
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Substance Abuse History
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Discussed SUD Treatment?
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Family Psychiatric History
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Psychiatric History
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Review of Systems, Active Medical Problems and Comorbidities (Notes if positive)
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Constitutional
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Eyes
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Ears/Nose/Mouth/Throat
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Cardiovascular
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Respiratory
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Gastrointestinal
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Musculoskeletal
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Integumentary
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Neurological
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Endocrine
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Hemotologic/Lymphatic
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Allergies/Immune
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Review of Systems Positive Details:
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Documentation / Treatment Plan
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Documentation Reviewed
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Details/Other:
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Medication Adjustments
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Benefits, Side Effects, and Risks of Medications discussed with patient?
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Consent from Patient/Guardian given?
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Treatment Plan
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In-House Orders for Procedures and Labs
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Other:
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Level of Risk
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Treatment Administration Dates (Established Patient Only)
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Date of last AIMS:
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Date of last Labs:
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Date of last OARRS:
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Date of last GENESITE:
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Additional Services
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Setting
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Client Status
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Was >50% of time used for counseling?
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Total Psychotherapy time (minutes)
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EM Level
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