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Chief Complaint
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Chief Complaint
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Current Sx
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ADHD Hyperactive/Impulsive Sympt
• • •
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Comments
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Energy
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Comments
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Sleep
• • •
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Comments
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Mood
• • •
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Comments
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PTSD
• • •
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Comments
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ADHD Inattentive Symptoms
• • •
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Comments
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Appetite
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Comments
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Concentration
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Comments
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Anxiety
• • •
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Comments
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Psychotic
• • •
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Comments
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HX of Presenting Problem
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New Short Text Field
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Review of Systems
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ROS unremarkable except for:
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General ROS:
• • •
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General Comments
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Head ROS:
• • •
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Head Comments:
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Cardiovascular ROS:
• • •
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CV Comments
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Respiratory ROS:
• • •
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Resp Comments
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GI ROS:
• • •
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GI Comments
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Skin ROS:
• • •
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Skin Comments
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Breasts ROS:
• • •
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Breasts Comments
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Urinary ROS:
• • •
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Urinary Comments
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Male GU ROS:
• • •
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Genital (Male) Comments
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Female GU ROS:
• • •
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Genital (Female) Comments
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MSK ROS:
• • •
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MSK Comments
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Neurological ROS:
• • •
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Neuro Comments
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Endocrine ROS:
• • •
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Endo Comments
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Mental Status Examination
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Appearance
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Personal Hygiene
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Eye Contact
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Psycho Motor Activity
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Alert and Oriented
• • •
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Behavior
• • •
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Mood
• • •
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Affect
• • •
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Speech
• • •
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Thought Content
• • •
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Attention Span
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Memory
• • •
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Insight and Judgment
• • •
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Psychotherapy note
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Type of Therapy Provided
• • •
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Session Length
• • •
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Presenting Problem
• • •
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Severity
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Concerns of client
• • •
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Onset
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Themes Discussed
• • •
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Therapy Interventions
• • •
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Interactive Complexity
• • •
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Diagnosis
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Diagnosis
• • •
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Mental Health Diagnosis (Clinicians)
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Treatment Goals
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Goal/Objective
• • •
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Progress
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Comments
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Assessment
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Assessment
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Treatment Plan
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Treatment Strategy/Interventions
• • •
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