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HISTORY OF PRESENT ILLNESS
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Medically Necessary Statement for Ongoing Care
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Initial ROS / Detailed
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Depression / SI
• • •
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Full Sentence(s)
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Anxiety
• • •
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Full Sentence(s)
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ADHD
• • •
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Full Sentence(s)
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PTSD
• • •
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Full Sentence(s)
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SUD
• • •
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Full Sentence(s)
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OCD
• • •
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Full Sentence(s)
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Thought Disorder / Impulsivity / HI
• • •
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Full Sentence(s)
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Depression Rating
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Anxiety Rating
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Primary Symptom (List)
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Primary Symptom Rating
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Trigger (list)
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Relieving factor (list)
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Impairment
• • •
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Energy
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comment (not FS)
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Concentration
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comment (not FS)
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Appetite
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comment (not FS)
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Eating Habits
• • •
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comment (not FS)
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Sleep Habits
• • •
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comment (not FS)
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Active Psychosis (AH/VH/Paranoia/Delusions) or Acute Mania
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Active SI/HI
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Obsessions/Compulsions
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Screened (+) for active SUD?
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Med Changes/ Intervention
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PDMP Reviewed this Visit?
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PDMP Comments
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Med Changes (full sentences)
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HISTORY
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INITIAL or DETAILED PAST HISTORY
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PSYCHIATRIC HISTORY
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Psych Hx
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Psychotropic History
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Med List at Intake (Medical, OTC, External)
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Med List at Intake (Psychotropics)
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SOCIAL HISTORY
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Alcohol
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Comments
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Drug Use
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Comments
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Tobacco
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Caffeine
• • •
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Cessation Counseling (any form of use)
• • •
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Currently in NA/AA?
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Birth Place
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Occupation
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Education
• • •
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Marital Status
• • •
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Living Arrangements
• • •
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Sexual Preference
• • •
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Access to Firearms
• • •
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Other: Children, Legal, Military, Religion, etc.
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MEDICAL HISTORY
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Medical History
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Rule Outs (Pregnancy, Neuro, Metal Above Neck))
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Surgical History
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PCP
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External Medical Meds
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FAMILY HISTORY
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Father's MH
• • •
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Comments
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Mother's MH
• • •
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Comments
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Other Blood-Relatives:
• • •
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Comments
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Review of systems
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Constitutional
• • •
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Comments (List +/-)
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EENT
• • •
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Comments (List +/-)
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Cardiac
• • •
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Comments (List +/-)
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Respiratory
• • •
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Comments (List +/-)
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GI
• • •
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Comments (List +/-)
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GU
• • •
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Comments (List +/-)
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Musculoskeletal
• • •
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Comments (List +/-)
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Derm
• • •
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Comments (List +/-)
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Neuro
• • •
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Comments (List +/-)
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Psych
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Functional Finding
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Independent ADLs?
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Abnormal (Macro)
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