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Chief Complaint
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Clinical ID
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PCP
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HPI
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HPI
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Current psychiatric medications:
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1. Medication
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Medication Name
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Dates
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effectiveness
|
side effects
|
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2. Medication
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Medication Name
|
Dates
|
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effectiveness
|
side effects
|
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3. Medication
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Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
4. Medication
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|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
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5. Medication
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Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
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6. Medication
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|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
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7. Medication
|
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|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
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8. Medication
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Medication Name
|
Dates
|
|
effectiveness
|
effectiveness
|
|
Past Psychiatric Medications
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1. Medication
|
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|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
2. Medication
|
|
|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
3. Medication
|
|
|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
4. Medication
|
|
|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
5. Medication
|
|
|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
6. Medication
|
|
|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
7. Medication
|
|
|
Medication Name
|
Dates
|
|
effectiveness
|
side effects
|
|
8. Medication
|
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|
Medication Name
|
Dates
|
|
side effects
|
side effects
|
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Psychiatric ROS
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|
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Mood:
• • •
|
Mood
|
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Anhedonia
|
Anhedonia:
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Sleep: # hours sleep per night
|
Sleep: # minute time to fall asleep
|
|
Sleep:# MCA
|
Sleep: EMA
|
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Sleep: DGGOB
|
Sleep: Comments
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Energy
|
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Concentration
|
Concentration
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Guilt
|
Guilt
|
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Appetite
|
Appetite:
|
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Psychomotor
|
Psychomotor
|
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SI
• • •
|
SI
|
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HI
|
HI
|
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Manic Sx
|
if yes, please choose
• • •
|
|
Manic Sx
|
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Anxiety Sx
|
if yes, please choose
• • •
|
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Anxiety Sx
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Panic Attacks
|
Panic Attacks
|
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Memory
|
Memory
|
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Psychotic Sx: If yes, please select on the following dropdown
|
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Delusions
|
Delusions
|
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Paranoia
|
Paranoia
|
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AH
|
AH
|
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VH
|
VH
|
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Other psychotic sx
|
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Functional impairments
|
Functional impairments
|
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Medical Review of Systems:
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Gen:
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Other
|
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Past Psychiatric History
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Past diagnoses
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Past hospitalizations
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Past suicide attempts
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Previous Psychiatrists
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Therapy history
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Past Medical History
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Social History
|
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Marital Status
|
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Etoh
|
If yes
|
|
Tob
|
If yes
|
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Substance Use
|
If yes
|
|
Additional Social History
|
|
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Family Psychiatric History
|
|
|
Family Psychiatric History
|
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Mental Status Exam
|
|
|
General
• • •
|
General
|
|
Appearance
• • •
|
Appearance
|
|
Behavior
• • •
|
Behavior
|
|
Speech
• • •
|
Speech
|
|
Mood
• • •
|
Mood
|
|
Affect
• • •
|
Affect
|
|
Thought Process
• • •
|
Thought Process
|
|
Thought Content
• • •
|
Thought Content
|
|
SI
• • •
|
SI
|
|
HI
|
HI
|
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Judgment
• • •
|
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Insight
• • •
|
|
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Cognition
• • •
|
Cognition
|
|
Motor
• • •
|
Motor
|
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Medications
|
|
|
1. Medications
|
2.Medications
|
|
3.Medications
|
4.Medications
|
|
5.Medications
|
6.Medications
|
|
7.Medications
|
8.Medications
|
|
|
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|
Lab Results
|
|
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DSM5 Diagnoses
|
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Assessment
|
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Plan
|
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