|
Medication compliance is good
|
If no, Explain
|
|
Eating well
|
If no, Explain
|
|
Sleeping well
|
If no, Explain
|
|
Caring for personal needs
|
If no, Explain
|
|
Taking care of responsibilities, i.e. housework, home, or school
|
if no, Explain
|
|
Current Safety Issues
• • •
|
Leathality
• • •
|
|
Narrative/Intervention RE: Safet
|
Sociopathy Risk
• • •
|
|
History of Suicide Attempt
|
Suicide Attempt Narrative
|
|
Presence of suicidal thoughts
• • •
|
ARNP Comments
|
|
Acute and Dynamic Risk Factors
• • •
|
ARNP Comments
|
|
Static Risk Factors
• • •
|
ARNP Comments
|
|
Protective Factors
• • •
|
ARNP Comments
|
|
Suicide Risk Level
|
ARNP Comments
|
|
Treatment changes made for moderate or high risk
• • •
|
ARNP Comments
|
|
Assessment
• • •
|
|
|
PATIENT SCREENING TOOLS
|
Screenings Completed:
|
|
AUDIT SCORE
|
|
|
DAST 10 Score (Score 1 point for each question answered "Yes," except for question 3 for which a "No" receives 1 point):
|
|
|
PHQ9 Scoring
|
PHQ-9:
|
|
Positive Depression Screen
|
Negative Depression Screen
|
|
MDQ Q1 (7 positive answers out of the 13 questions in part I)
|
|
|
Mood Disorder Questionnaire PART 1 SCORE:
|
|
|
MDQ Q2 (Positive response to the first question of part II)
|
|
|
If you checked YES to more than one of the above, have several of these ever happened during at least a four day period of time?
|
|
|
MDQ Q3 (Moderate or severe response to the second question of part II)
|
|
|
How much of a problem did any of these cause you -
|
|
|
Mood Disorder Questionnaire Comments:
|
|
|
Vanderbilt Assessment Scale - Parent Assessment Scale
|
|
|
Was score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on questions 48-55?
|
|
|
Was score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on questions 48–55?
|
|
|
Did patient test positive on the above criteria on both inattention and hyperactivity/impulsivity?
|
|
|
Was score a 2 or 3 on 4 out of 8 behaviors on questions 19–26 AND Score a 4 or 5 on questions 48–55?
|
|
|
Was score a 2 or 3 on 3 out of 14 behaviors on questions 27–40 AND Score a 4 or 5 on questions 48–55?
|
|
|
Was score a 2 or 3 on 3 out of 7 behaviors on questions 41–47 AND Score a 4 or 5 on questions 48–55?
|
|
|
Vanderbilt Parent ADHD Scale:
|
|
|
PTSD CHECKLIST
|
|
|
At least 1 answer of 3, 4 or 5 points at questions 1 to 5?
|
At least 3 answers of 3, 4 or 5 points at questions 6 to 12
|
|
At least 2 answers of 3, 4 or 5 points at questions 13 to 17
|
|
|
PTSD POSITIVE?
|
|
|
ASRS v 1.1
|
|
|
Part A Score
|
Part B Score
|
|
Adult ADHD Self Report Score:
|
|
|
GAD 7
|
|
|
1. Feeling nervous, anxious or on edge
|
2. Not being able to stop or control worrying
|
|
3. Worrying too much about different things
|
4. Trouble relaxing
|
|
5. Being so restless that it is hard to sit still
|
6. Becoming easily annoyed or irritable
|
|
7. Feeling afraid as if something awful might happen
|
|
|
Total Sum of 1 - Several Days
|
Total Sum of 2 - More than half the days
|
|
Total Sum of 3 - Nearly every day
|
Total Score
|
|
General Self Efficacy Scale
|
|
|
GSE Total Score: GSE scores range from 10 to 40, where the higher the score, the greater the individual’s generalized self-effic
|
|
|
Satisfaction with Life Scale
|
Satisfaction with Life Scale
|
|
Oswestry Disability Index (ODI) For Low Back Pain
|
Oswestry Disability Index (ODI) For Low Back Pain
|
|
Opioid Risk Tool
|
|
|
1. Gender
|
Age between 16 and 45 (Female 1, Male 1)
|
|
2. Family history of substance abuse
|
|
|
Alcohol Abuse in Family (Female 1, Male 3)
|
Illegal Drug Use in Family (Female 2, Male 3)
|
|
Prescription Drug Abuse in Family (Female 4, Male 4):
|
|
|
3. Personal history of substance abuse
|
|
|
Alcohol Abuse (Female 3, Male 3)
|
Illegal Drug Use (Female 4, Male 4)
|
|
Prescription Drug Abuse (Female 5, Male 5):
|
|
|
4. Sexual abuse and psychological disease:
|
|
|
History of preadolescent sexual abuse (Female 3, Male 0):
|
ADD, OCD, bipolar, schizophrenia (Female 2, Male 2):
|
|
Depression (Female 1, Male 1):
|
|
|
Opioid Risk Tool Score:
|
|
|
Clinical Opiate Withdrawal Scale (COWS):
|
|
|
1. Resting Pulse Rate (bpm):
|
2. Sweating:
|
|
3. Restlessness observation during assessment:
|
|
|
4. Pupil Size:
|
5. Bone or Joint Aches:
|
|
6. Runny nose or tearing:
|
7. GI Upset:
|
|
8. Tremor observation of outstretched hands:
|
9. Yawning observation during assessment:
|
|
10. Anxiety or irritability:
|
11. Gooseflesh skin:
|
|
COWS Result:
|
|
|
CAGE (Drinking Assessment)
|
|
|
Have you felt like you should cut down?
|
Ever felt bad or guilty about drinking?
|
|
Have people annoyed you by criticizing your drinking?
|
Drink to cure hangover/steady nerves?
|
|
CAGE Score
• • •
|
|
|
ETOH counseling
|
ETOH Counseling Notes
|
|
Cognitive Functioning:
|
Functional Finding
|
|
Tobacco Cessation Counseling
|
|
|
Tobacco use amount
• • •
|
Interested in Quitting
|
|
Symptomatic
|
Motivational Counseling
• • •
|
|
Recommended Resources
• • •
|
Medication
• • •
|
|
Current Medications/Adjustments:
|
|
|
ICD 10 Codes
• • •
|
Billing Code
|
|
ALCOHOL CESSATION COUNSELING
|
|
|
EtOH
• • •
|
Interested in Quitting
|
|
Symptomatic
|
Motivational Counseling
• • •
|
|
Medication
• • •
|
Current Medications/Adjustments:
|
|
Recommended Resources
• • •
|
Billing Code
|
