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PRESENTING PROBLEM:
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SYMPTOM DESCRIPTION AND SUBJECTIVE REPORT:
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Respiration rate
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Normal Musculoskeletal
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CURRENT MENTAL STATUS:
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GENERAL APPEARANCE:
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DRESS:
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Motor Activity:
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Insight:
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Judgment:
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Speech:
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Affect:
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Mood:
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Orientation:
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Memory:
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Attention/Concentration:
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Thought Content:
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Perception:
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Flow of Thought:
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Interview Behavior:
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Additional Information
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SAFETY ISSUES ***REQUIRED***
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Safety Issues: DO YOU HAVE ANY CURRENT THOUGHTS OF HARMING YOURSELF OR OTHERS?
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If yes, please complete the following below:
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Suicidal Ideation:
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Self-Injuring Behavior:
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Other:
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Homicidal Ideation:
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Medical History:
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Medical Allergy:
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Current Medications:
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Additional Information:
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Are you Sexually Active? PLEASE OPEN THE SWITCH TO VIEW QUESTIONS
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Do you use a form of contraception?
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Current sexual partner information
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Contraception / Precaution:
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FOR WOMEN ONLY. PLEASE OPEN THE SWITCH TO VIEW QUESTIONS
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Last menstrual period / Contraception / STI protection / other details:
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Are you currently trying to become pregnant?
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Caffeine / Nicotine Use
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ALCOHOL USE
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Amount & Frequency or Treatment Information
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Substance Use
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Type / Amount / Frequency / Treatment/ Last Use:
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Education / Occupation:
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Education / Occupation:
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Family Relationship Status:
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Current Relationship status:
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Relationship Status / Information
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Children / Dependents:
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Social History:
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Social support:
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Significant relationship History:
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Legal Issues
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Current litigation or legal involvement:
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Current Relevant Content:
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Sleeping:
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Sleep Disruption:
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Details:
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Eating:
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Appetite/weight changes within last month
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Disrupted Eating Patterns:
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Details:
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Sexuality / Current Sexual Activity:
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Sexuality:
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Other Important personal information:
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Past Psychiatric History:
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Pertinent History of Psychiatric Medications and Therapy
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Hx of mania symptoms such as
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Additional Information
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Past Psyciatric Diagnoses
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Current Psychiatric Issues
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Depression Rating
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Anxiety rating scale
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Major Depressive Disorder Symptoms
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Depressive disorder comments:
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GAD physical symptoms
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Anxiety/Panic comments
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Mania symptoms reported:
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Bipolar/manic symptom comments
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Obsessive Compulsive Disorder
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OCD comments:
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PTSD
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PTSD comments:
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Hyperactivity type symptoms
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Inattentive Criteria Symptoms
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Other Mental Health Issues
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ADHD Assessment comments
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OBJECTIVE
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OBJECTIVE NOTES:
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DIAGNOSTIC
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DIAGNOSTIC IMPRESSIONS:
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Assessments used:
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Additional Information
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Diagnosis ICD-10:
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CPT:
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TREATMENT PLAN
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PLAN:
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Laboratory Testing:
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Imaging/ Diagnostic Testing:
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Goals:
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Additional information
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Discharge Plan:
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INTERVENTION:
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Select all that apply:
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Comments:
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AGREEMENTS:
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Additional Information
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Patient:
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MEDICATION:
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SSRI:
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SNRI:
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Serotonin Modulators:
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Tricyclic:
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NRI & Alpha Agonist:
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Anxiolytic (Non-benzo):
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Beta Adrenergic (BB):
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H-Anxiolytic:
• • •
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Antipsychotic:
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Anti-Convulsant:
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BPDO
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Stimulants:
• • •
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Supplements:
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Other
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RECOMMENDATION:
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Continue Current Treatment Plan
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Comment:
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Medication Instruction
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Comment:
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Change / Add On Therapy Treatment
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Comment:
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Terminate Treatment
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Comment:
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** FOLLOW UP VISIT:
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return in
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