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Length of Session
|
|
|
Who presented in office with patient?
|
|
|
Location of meeting
|
|
|
HISTORY OF PRESENT ILLNESS
|
|
|
History of Present Illness:
|
|
|
Depression:
• • •
|
Depression
|
|
Mania:
• • •
|
Mania:
|
|
Anxiety:
• • •
|
Anxiety:
|
|
Psychosis:
• • •
|
Psychosis:
|
|
Sleep:
• • •
|
Sleep:
|
|
ADHD:
• • •
|
ADHD:
|
|
Eating Disorder Symptoms:
• • •
|
Eating Disorder Symptoms:
|
|
Suicidality/Homicidality
|
Suicidality/Homicidality
|
|
PAST PSYCH HISTORY
|
|
|
Prior Hospitalizations
|
|
|
Outpatient Tx
|
|
|
Suicide Attempts/ SIB
|
|
|
Prior Meds
|
|
|
Current Meds
|
|
|
Family psych history
|
|
|
MEDICAL HISTORY
|
|
|
Medical Problems
|
|
|
Surgeries
|
|
|
Head Injury
|
|
|
Medications
|
|
|
Diet/ Exercise
|
|
|
Reproductive HISTORY
|
|
|
SOCIAL HISTORY
|
|
|
Legal History/ History of Violence
|
|
|
Developmental History
|
|
|
Trauma and Abuse history
|
|
|
Education/ Occupation
|
|
|
Relationships
|
|
|
Children
|
|
|
Support
|
|
|
Other
|
|
|
SUBSTANCE ABUSE HISTORY
|
|
|
Tobacco
|
|
|
Drugs
|
|
|
Alcohol
|
|
|
Caffeine
|
|
|
REVIEW OF SYSTEM
|
|
|
General [-]
|
General
• • •
|
|
General Comments
|
|
|
Skin [-]
|
Skin
• • •
|
|
Skin Comments
|
|
|
HEENT [-]
|
HEENT
• • •
|
|
HEENT Comments
|
|
|
Cardiovascular [-]
|
Cardiovascular [-]
|
|
CV Comments
|
|
|
Respiratory [-]
|
Respiratory
• • •
|
|
Resp Comments
|
|
|
GI [-]
|
GI
• • •
|
|
GI Comments
|
|
|
Urinary [-]
|
Urinary [-]
|
|
Urinary Comments
|
|
|
MSK [-]
|
MSK
• • •
|
|
MSK Comments
|
|
|
Neurological [-]
|
Neurological
• • •
|
|
Neuro Comments
|
|
|
Endocrine [-]
|
Endocrine
• • •
|
|
Endo Comments
|
|
|
MENTAL STATUS EXAM
|
|
|
General Appearance:
|
General Appearance:
|
|
Gait:
|
Gait:
|
|
Orientation Alert & Oriented to Time:
|
Orientation Alert & Oriented to Time:
|
|
Behavior:
|
Behavior:
|
|
Speech & Language :
|
Speech & Language :
|
|
Mood:
|
Mood:
|
|
Affect:
|
Affect:
|
|
Thought Content:
|
Thought Content:
|
|
Thought Process:
|
Thought Process:
|
|
Associations:
|
Associations:
|
|
Attention/Concentration:
|
Attention/Concentration:
|
|
Recent & Remote Memory:
|
Recent & Remote Memory:
|
|
Fund of Knowledge:
|
Fund of Knowledge:
|
|
Insight/Judgement:
|
Insight/Judgement:
|
|
|
|
|
Summary
|
|
