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Psychiatric Note
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Psychiatric Note
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New Patient
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Follow up
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Referral Source
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Reason for Evaluation
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ID and HPI
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Follow up
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Family Psychiatric History
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Family History of Mental Health
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Conditions or Events
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Personal History
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Hometown
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Birth complications for patient
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Developmental delays
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Personal History
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Traumas
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Enduring traits
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Psychosocial History
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Currently living with
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Living arrangements
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Pronoun preferred
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Sexual preference
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Current relationships
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Relationship History/Support System
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Activities, hobbies
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Occupational History
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Currently working
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Work history
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Military service
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Highest level of education
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Currently a student
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Major in college
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Attending class consistently
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Any accommodations needed
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List accommodations
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Expected graduation
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Long term plans
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Medical History
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PCP
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Previous medical conditions and surgeries
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Active medical problems
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Disordered eating history
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History of pregnancies
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Pregnancy or Postpartum Complications
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Children
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How many? What age are they?
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Allergies
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Current prescription medications
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OTC/Herbal supplements
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Substance Abuse
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Caffeine
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Nicotine
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ETOH
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MJ
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Stimulant
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Hallucinogenic 
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Benzos/Opiates 
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History of IV drug use, attempts to quit, substance use medical detoxes or treatment facilities
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Legal history
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Past Psychiatric History
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Mental Health History
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Diagnoses history
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Medication trials
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Inpatient hospitalizations
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Suicide attempts
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Self-harm behaviors
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Protective factors
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Most recent psychiatric provider
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Access to firearms
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Counseling
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Review of Systems
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Constitutional
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Comment
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Eye
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Comment
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ENMT
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Comment
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Respiratory
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Comment
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Cardiovascular
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Comment
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Gastrointestinal
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Comment
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Genitourinary
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Comment
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Musculoskeletal
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Comment
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Integumentary
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Comment
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Neurologic
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Comment
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Psychiatric
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Comment
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Mental Status Exam
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General Appearance
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Age
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Build
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Dress
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Grooming and hygiene
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Gait
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Muscle strength and tone
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Speech
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Psychomotor
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Eye contact
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Mood and Affect
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Mood
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Affect
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Thought process
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Thought content
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Suicidal
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Homicidal
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Obsessions
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Phobias
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Hallucinations
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Paranoia
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Mental Status
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Memory
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Attention span/concentration
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Intellect
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Judgement
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Insight
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Assessment and Plan
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Diagnostic Tools
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Screening Tools used, See below for forms
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Formulation
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Summary
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Diagnoses
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Plan
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Additional Recommendations
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Records requested
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Counseling referral
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Labs ordered
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Prescriptions sent
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Prescription Drug Monitoring
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Safety concerns addressed
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Testing needed
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Access to firearms
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Follow up
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Default Plan
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