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Medication Management
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Symptoms
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Loss of Interest
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Frequency / Duration
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Down‚ Depressed or Hopeless
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Frequency / Duration
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Trouble Sleeping
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Frequency / Duration
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Appetite
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Frequency / Duration
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Feelings of Failure
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Frequency / Duration
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Concentration
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Frequency / Duration
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Psychomotor Retardation / Agitation
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Frequency / Duration
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Anxiety
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Frequency / Duration
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Irritability
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Frequency / Duration
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Panic Attacks
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Frequency / Duration
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Trouble Relaxing/Restlessness
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Frequency / Duration
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Flashbacks
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Frequency / Duration
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Racing thoughts
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Frequency / Duration
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Intrusive Thoughts
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Frequency / Duration
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Nightmares
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Frequency / Duration
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Avoidance
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Frequency / Duration
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Hypervigilance
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Frequency / Duration
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Exaggerated Startle
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Frequency / Duration
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Dissociation
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Frequency / Duration
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Restricting/Binge Eating
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Frequency / Duration
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Obsessions/Compulsions
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Frequency / Duration
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Grandiosity
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Frequency / Duration
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Decreased need for sleep
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Frequency / Duration
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Reckless behavior
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Frequency / Duration
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Pressured Speech
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Frequency / Duration
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Flight of Ideas/Circumstantial/Tangential
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Frequency / Duration
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Goal directed behavior
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Frequency / Duration
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Paranoia
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Frequency / Duration
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Hallucinations
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Frequency / Duration
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Delusions
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Frequency / Duration
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Additional Symptoms notes
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Suicide/Self Harm/Homicide Assessment
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Suicidal Ideation
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CSSRS completed?
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Suicide Safety Plan Completed
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Comments: Suicidal Ideation
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Self Harming Behavior
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Comments: Self Harming Behavior
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Homicidal Ideation
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Homicidal Safety Plan Completed
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Comments: Homicidal Ideation
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Additional Symptoms notes
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Substance Use
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Alcohol
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Last use
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Frequency / Duration
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Nicotine
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Last use
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Frequency / Duration
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Cannabis
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Last use
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Frequency / Duration
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Crack/Cocaine
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Last use
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Frequency / Duration
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Amphetamines (Meth, Adderal, Ritalin)
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Last use
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Frequency / Duration
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Opiates (Perocet, Vicodin)
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Last use
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Frequency / Duration
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Heroin
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Last use
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Frequency / Duration
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Hallucinogens (Mesculin, Mushrooms, PCP)
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Last use
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Frequency / Duration
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Benzodiazepines (Clonapin, Xanax, Valium)
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Last use
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Frequency / Duration
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Inhalants
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Last use
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Frequency / Duration
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Gambling
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Last use
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Frequency / Duration
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Other
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Last use
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Frequency / Duration
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Intervention/Patient Response
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Compliance
• • •
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Comments
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Prn’s required
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Comments
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Compared to last visit presentation
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Comments
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Current Medications Reviewed
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Comments
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Date of medication adjustments
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Medication side effects evident
• • •
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Comments
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Medication Concerns per patient
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Comments
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Interventions and Patient Response
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Follow Up
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Mental Status Examination
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JUDGEMENT
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INSIGHT
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BEHAVIOR
• • •
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HOMICIDALITY
• • •
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SUICIDALITY
• • •
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Dissociation
• • •
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Delusions
• • •
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Hallucinations
• • •
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PERCEPTION
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ATTENTION
• • •
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MEMORY
• • •
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ORIENTATION
• • •
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MOOD
• • •
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AFFECT
• • •
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MOTOR ACTIVITY
• • •
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EYE CONTACT
• • •
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SPEECH
• • •
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APPEARANCE
• • •
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Other
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