Pediatric Mental Health

[comment memo="Duplicate of existing form"]

Chief Complaint: 
[textarea name="variable_1" default=""]

Subjective:
Patient reports [select name="variable_1" value="improved symptoms| worsening symptoms| no changes"] since the last visit.
Symptoms: Sleep is [select name="variable_2" value="good| fair| poor| terrible| improving| sleeping too much| sleeping too little"], appetite is [select name="variable_3" value="good| fair| poor| terrible| improving| overeating"], energy levels are [select name="variable_4" value="Good| Fair| Poor| Terrible| can't sit still"], concentration is [select name="variable_5" value="Good| Fair| Poor| terrible| Not discussed"]
Informant: [text name="variable_1" default=""]
Pt is currently displaying [select value="symptoms of| well managed| moderately managed| poorly managed"]:[checkbox value="depression| anxiety| sleep disturbance| psychosis| substance abuse| cognitive impairment| impulsivity| mood lability| alcohol dependence| opiate dependence| autism spectrum disorder| hyperactivity"][textarea memo="other" default="" rows="1"]
History of Present Illness:
Patient is a [text memo="age" size="2"]-year-old,[checkbox value="Caucasian| African-American| Hispanic| Asian| Native American"] [checkbox value="female| male| transgender female| transgender male| non-binary individual"] [select name="variable_9" value="with no past psychiatric history| with history of"]
[checkbox value="depression| MDD| situational depression| anxiety| panic attacks| mood disorder| bipolar disorder| somatic symptoms| somatic symptom disorder| ADHD| PTSD| OCD| psychosis| substance abuse| personality disorder| maladaptive personality traits| recurrent suicidal ideation| suicide attempt| schizoaffective disorder| schizophrenia| psychosis| unknown mental health diagnosis| severe persistent mental illness| psychiatric hospitalization| noncompliance with psychiatric medications/treatment"][textarea memo=" " rows="5"] 
The Pt identifies the following symptoms: [checkbox value="irritability| mood instability| heightened anxiety| attention problems| fearfulness| nightmares| sleep disturbances| depressed| aggression| violence| impulsive| withdrawn| delusional| auditory hallucinations| visual hallucinations"]
Which is described as:[checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"]
Allergies: [select value="NKA| Allergic to"][textarea memo="other" default="" rows="1"]
Medications:
[textarea name="variable_1" default=""]
FAMILY PSYCHIATRIC HISTORY
[select value="denies knowledge of a family history of mental illness| Family history of mental health/substance/alcohol problems is positive for | Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="4"]. 
SOCIAL HISTORY:
Living situation: [select value="lives with parents| lives with grandparents| lives in a group home| lives with foster parents| lives with mother| lives with father| other"]
Patient identifies [checkbox value="having no one| significant other| family| friends| church members"] as social-support. Patient has [select value="0| 1| 2| 3| 4| 5| 6| 7"] siblings. Patient is in [select value="high school| junior high school| grade school| alternative school"].  Patient identifies as [select value="| Christian| Catholic| Muslim| Jewish| Spiritual but not practicing| Athiest| Agnostic"]  [select value="They have no current legal concerns| Legal concerns include| Legal concerns were not addressed"] [textarea rows="3"]
Medical history:[text name="variable_10" default=""]
Alcohol/Drug Use:[text name="variable_11" default=""]
Past psychiatric history:[text name="variable_12" default="]
Objective:
Vitals:
B/P [text name="variable_2" default=""] mmHg 
HR [text name="variable_3" default=""] bpm 
RR. [text name="variable_4" default=""] rpm
Ht. [text name="variable_5" default=""] inches
Wt. [text name="variable_6" default=""] lbs. 
BMI [text name="variable_7" default=""]
Mental Status Examination
Mood:[checkbox value="euthymic| depressed| anxious| angry| irritable| happy| fluctuating"]
Affect:[checkbox value="constricted| normal range| shallow| flattened| restricted| irritable| full range| congruent"]
Speech: [select value="Normal rate and rhythm| pressured| latency| monotone| coherent| fluent"]
Thought process: [select value="logical, linear, age appropriate| circumstantial| flight of ideas| word salad"]
Associations: [select value="intact| loose| tangential"]
Thought Content: [select value="no evidence of delusions| evidence of delusions"], [select value="no evidence of response to internal stimuli| responding to internal stimuli"], [select value="no suicidal or homicidal ideation or intentions| evidence of suicidal or homicidal ideations or intentions"], [select value="no homicidal ideation or intentions"]
Orientation: [select value="Oriented to person, place, and time| unable to assess"]
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions| unable to assess| impaired attention and concentration"]
Memory: [select value="Recent and remote memories both intact based on Pt's answers to interview questions| unable to assess |recent memory impairment| remote memory impairment"]
Judgment: [select value="fair| good| poor| impulsive"]
Insight: [select value="fair| good| poor"]
Knowledge: Based on the answers to interview questions, Pt's intelligence is judged to be [select value="average| above average| below average| unable to assess"]
Assessment:
Axis I: Psychiatric Illness
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Axis II: Chronic Developmental Disorders and Personality Disorders
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Axis III: Physical Conditions
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Axis IV: Psychosocial Stressors
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Axis V: Global Assessment of Functioning (GAF)
Current GAF
[select name="Q1" value="91-100: Higher level functioning in broad range of activities with good and control of typical life stressors|81-90: Other than mild psychiatric symptoms for common triggers, good level of functioning|71-80: Mild psychiatric symptoms with triggers and mild impact on functioning|61-70: Mild psychiatric symptoms with impact on functioning, but overall functioning is good and relationships are maintained|51-60: Moderate psychiatric symptoms with moderate impact on functioning|41-50: Serious symptoms and impaired functioning|31-40: Impaired reality and major Impairment|21-30: Delusions, hallucinations, or serious Impairment|11-20: Danger to self or others|1-10: Persistent danger to self or others"]
Plan:
Treatment is [select name="variable_24" value="recommended| not recommended"].
The following interventions were ordered/ recommended this appointment:
-[select value="Begin| continue| N/A"] medication(s): [textarea default=""]
-Consult for: [select value="therapy| testing| medical| other"] 
[textarea name="variable_25" default=""]
-Orders/testing:  
[textarea name="variable_26" default=""]
-Parent/patient psychoeducation completed
-Monitor medication compliance and side effects
Follow up: 
-[select value="in 1 week| in 2 weeks| in 4 weeks| in 2 months"]
I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. Plan of care reviewed with patient and agreed with current regimen. Patient advised if any homicidal or suicidal ideation to call 911 or go to the nearest ER.