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EIN/ NPI/ LICENSE
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Infusion #
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Rating Scales:
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PHQ-9
|
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GAD-7
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WHO-5
|
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PCL-5
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McGill
|
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SE:
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S:
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MSE:
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Appearance:
• • •
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A & O:
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Behavior:
• • •
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Speech:
• • •
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Affect:
• • •
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TP:
• • •
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Cognition:
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Insight
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Judgement
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Mood
• • •
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Mood (Patient Quote)
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SI:
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SI
|
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Contracts for Safety
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HI
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HI
|
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Psychosis
|
|
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Auditory Hallucinations
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Auditory Hallucinations
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Visual Hallucinations
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Visual Hallucinations
|
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Diagnostic Impression:
|
|
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DI: Major Depressive Disorder
• • •
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DI: Other Disorders
• • •
|
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DI: Bipolar
• • •
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DI: Eating Disorders
• • •
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DI- Substance Use Disorders:
• • •
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DI- ADHD
• • •
|
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DI: Cognition
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DI: (If not listed as favorite above)
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Alcohol/ Illicit Drugs:
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If Pt uses alcohol/ illicit drugs, explain:
|
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Medication Compliance:
|
If Pt is NOT medication compliant, explain:
|
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LFT's Checked:
|
LFTs:
• • •
|
|
History of liver disease?
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Any active bladder issues?
|
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Plan
• • •
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Additional Plan Notes:
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