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Subjective
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Chief Complaint
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Past medical problems
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Previous Surgeries
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Allergies
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Current Prescriptions
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Past Psychiatric Prescriptions
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OTC meds
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Supplements
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Pain
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Women Only
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Menstrual History
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Pregnancy History
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Hormone and Birth Control History
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Past psychiatric diagnosis
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Past psychiatric or counseling treatment
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Past suicidal or self-harm
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Family history of mental health disorders suicides or drug addictions
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Family Dynamics
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Current or Past Relationships
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Legal Problems
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Religion
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Trauma or abuse
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Brain Injury
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Willing to try medication or treatment
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Review of Symptoms
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Depression
• • •
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Mania
• • •
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Suicidal Ideation
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If yes, please describe
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Drug Induced Mood disorder
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Psychosis/Schizophrenia
• • •
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If 2 Psychosis/Schizophrenia are yes, select all that apply
• • •
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Anxiety
• • •
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Panic
• • •
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PTSD
• • •
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ADHD
• • •
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Asperger's/Autism
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1.
• • •
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2.
• • •
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3. Developed early in development and are persistent
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4. The disturbances are not better explained by intellectual developmental disorder or global developmental delay
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Somatoform
• • •
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Personality Disorder
• • •
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Objective
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MENTAL STATUS EXAM (MSE)
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General Observations
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Appearance
• • •
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Comments
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Build/Stature
• • •
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Comments
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Posture
• • •
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Comments
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Eye Contact
• • •
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Comments
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Activity
• • •
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Comments
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Attitude Toward Examiner
• • •
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Comments
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Attitude Toward Parent/Guardian
• • •
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Comments
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Separation (for Children/Adolescent)
• • •
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Comments
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Mood
• • •
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Comments
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Affect
• • •
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Comments
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Speech
• • •
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Comments
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Thought Process
• • •
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Comments
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Perception
• • •
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Comments
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Thought Content
• • •
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Comments
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Delusions
• • •
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Comments
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Risk Assessment
• • •
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Comments
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Cognition
• • •
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Comments
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Intelligence Estimate
• • •
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Comments
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Judgment
• • •
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Comments
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Other
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Lab work or testing review
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If yes, please describe
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Assessment
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Plan
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