intake

*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]

Provider Location: home  
Patient Location: home  
 
Informed consent: This is a telehealth visit with the patient located in their home. The Provider informed the patient of the benefits and risks of telehealth, including the risk that personal information could be exposed during a telehealth visits, or that technical problems and/or the type of health problem being treated could result in suboptimal transmission of information for medical decision making. Patient understands they have the right to discontinue or refuse treatment at any time, and request the same service in a face-to-face setting. Patient verbalized consent for this visit.
 
The following was discussed with the patient by office staff: The patient was informed that the visit will be documented in the patient’s medical record, same as with face-to-face visits. The Patient understands they have the right to verify the identity of their telehealth provider
 
 
Intended Modality: Telehealth
Modality of Service performed: [select value="Successful video telehealth visit|Telephone visit due to video link being unavailable|Telephone visit due to patient declining video service|"][text memo="other" size="40"]
Total Time of Visit: [select value="60 min|10 min|15 min|20 min|25 min|30 min|45 min|60 min"][text memo="time" value="10"]
Greater than 50% of the visit was spent on counseling and education


Identifying Information:
[text name="name" memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"], [checkbox value="single|married|partnered"] [checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"][text memo="other gender" value="20"] who [select value="lives with their significant other|lives with their family|lives alone|is homeless|lives with their parents|lives with their children|lives with a roommate|lives in a grouphome|"][text size="20"] in [text memo="residing location" size="20"]. [select value="They are their own guardian|They have a DHS guardian |Their guardian is |"][text memo="guardian" size="20"].  [textarea memo="Additional presentation information" rows="5"]

History of Presenting Illness:
[var name="name"] [select value="presents in this outpatient appointment |initially presented to the emergency department "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |"][text memo="presenting problem" size="20"].  [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past history of |no history of mental health concerns until |no history of mental health concerns|"][textarea memo="Mental health history" rows="5"].  [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"]  

[var name="name"]'s depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"].  [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].[textarea memo="Additional Depression information" rows="5"][/conditional][conditional field="anxiety" condition="(anxiety).is('')"]  

[var name="name"]'s anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20].  [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"]

[select value="  Mood instability has been an issue since |"][text size="20"].  [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"].  [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"].  [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]

[select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"].  [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"].  Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment.  [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]

[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning.  [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"]  [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"].[/conditional][conditional field="adhd" condition="(adhd).is('')"]  These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"].  [textarea rows="3"][/conditional][conditional field="sleep" condition="(sleep).is('')"]

Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"].  They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night.  [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"].  [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"].  [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"].  [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional][conditional field="sleep" condition="(sleep).isNot('')"]Sleep is reported to be generally good.  [/conditional][conditional field="depression" condition="(depression).isNot('')"]They deny any marked issues with depression.  [/conditional][conditional field="anxiety" condition="(anxiety).isNot('')"]They deny any significant issues with anxiety.  [/conditional]

[select value="Current psychiatric medications include: |They are not currently taking any psychiatric medications|Patient is unable to recall current medications|Unable to cover current psychiatric medications with patient due to symptomatic presentation|"][textarea rows="4"].[select name="medmed" value=" Other medical medications include: | Other medical medications are noted below."][conditional field="medmed" condition="(medmed).isNot(' Other medical medications are noted below.')"][textarea rows="3"].[/conditional][select value="  Medication list obtained from patient.|  Medication list obtained from medical record.| Medication list obtained from patient's guardian. | Medication list confirmed with patient's pharmacy.| Medication list confirmed with patient's grouphome.| "] [select value="They are not currently receiving individual counseling/therapy|They are currently engaging in individual counseling with |"][textarea rows="1"].  [select value="They deny current suicidal ideation or thoughts of self harm|They report positive for |They deny suicidal ideation but state having thoughts of being better off dead"][textarea rows="1"].  [checkbox value="They are able to contract for safety.|They deny being able to contract for safety."][textarea rows="1"]  [select value="They deny having access to guns|They report positive for having guns in the home |"][textarea rows="1"].  [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]
[checkbox name="hidehcp" memo="Hide Healthcare Provider Section" value=""]
[conditional field="hidehcp" condition="(hidehcp).isNot('')"]Current Healthcare Providers:
[checkbox value="Primary Care:"] [textarea rows="1"][checkbox value="none"]
[checkbox value="Dental:"] [textarea rows="1"][checkbox value="none"]
[textarea memo="Other" rows="1"]
[/conditional][checkbox memo= "Scales" name="scales" value=""][conditional field="scales" condition="(scales).is('')"]
Scales and Screening:
PHQ-9: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
GAD-7: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
MDQ: [select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
HITS:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
PC-PTSD:[select value="negative|unable to assess|declined|1|2|3|4"]
AUDIT:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
DAST-10:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
SLUMS:[select value="N/A|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"][/conditional]


PSYCHIATRIC HISTORY:
[select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|We were unable to cover previous psychiatric medication trials due to symptomatic presentation|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"].  [select value="There is no history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="2"]. [select value="Previous psychiatric/counseling services includes |They have no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"]. [select value="They deny history of diagnosis/treatment for an eating disorder|They report positive for a history of diagnosis/treatment for an eating disorder including |Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation|History of diagnosis/treatment of an eating disorder was not assessed in this encounter|"][textarea rows="1"].[select value="They have no history of thoughts of self-harm|History of thoughts of self harm include |"][textarea rows="2"].  [select value="They have no history of attempting to hurt themself|History of self-harm includes |Unable to obtain history of self-harm due to symptomatic presentation"][textarea rows="2"].  [select value="They have no history of head injuries or traumatic brain injuries|They have a past history of traumatic brain injuries resulting from |They have an underlying cognitive impairment from |"][textarea rows="2"].  [select value="There is no history of trauma|They report having a history of trauma but did not want to elaborate|They report past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="2"].  [select value="They report positive for tobacco use consuming approximately |They report a past history of tobacco but quit approximately |They deny any tobacco use|"][textarea rows="1"].  [select value="They report positive for alcohol use consuming approximately |They report a history abuse quitting approximately |They deny any alcohol use|"][textarea rows="2"].  [select value="They deny a history of recreational substance use|They report utilizing cannabis approximately |They have a history of opiate use disorder |They report utilizing opiates recreationally in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="4"].

DEVELOPMENTAL HISTORY:
[var name="name"] was born in [text memo="place of birth" size="20"] [select value="to an intact family|to a family structure consisting of |"][textarea rows="1"].  [select value="There is no known issue with meeting expected developmental milestones|All developmental milestones were met with exception to |There were some notable issues with developmental milestones including |"]. Their primary language includes [select name="language" value="English|"][conditional field="language" condition="(language).is('')"][text memo="language" size="15"][/conditional] and utilizes [select name="comskill" value="written and verbal communication|primarily verbal communication|primarily textual communication and sign language| "][textarea rows="1"].

SOCIAL HISTORY:
[var name="name"] identifies [checkbox value="having no one|significant other|extended family|children|friends|church members"][textarea rows="1"] as their social-support network.  They have [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children.  Their level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"].  They are [select value="currently on disability due to their mental health condition|currently on disability due to their medical condition|currently employed |currently retired from |"][textarea rows="1"].  Financially they [select value="have no immediate concerns|are burdened by healthcare costs|have concerns related to supporting their family|"][textarea rows="1"].  Their source of income is primarily [select value="disability|social security|unemployment|current employment|family support|retirement|"][textarea rows="1"].  They have [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="1"].  [select name="spirituality" value="Spirituality was not addressed this visit|Spirituality is identified as |"][conditional field="spirituality" condition="(spirituality).is('Spirituality is identified as ')"][select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"][/conditional].  [select value="Cultural considerations important to care include: |"][textarea rows="1"].  Sexual orientation [select name="sexuality" value="is identified as |was not addressed this visit|"][conditional field="sexuality" condition="(sexuality).is('is identified as ')"][select value="heterosexual|homosexual|bisexual|pansexual|asexual|"][textarea rows="1"][/conditional].  [select value="They have no military history|Military history includes |Military history was not addressed this visit|"][textarea rows="1"].  [select value="They have no current legal concerns|Legal concerns include |Legal concerns were not addressed due to symptomatic presentation"][textarea rows="1"].

FAMILY PSYCHIATRIC HISTORY:
[select value="They deny knowledge of a family history of mental illness|Family history of mental health problems is positive for |Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="4"].  [select value="There is no known history of suicides or self-harm in the patient's family|Family history of suicides/self-harm includes |Unable to cover family history of suicides/self-harm due to symptomatic presentation|"][textarea rows="2"].  [select value="There is no known family history of substance use issues|Family history of substance use is positive for |Unable to cover family history of substance use issues due to symptomatic presentation|"][textarea rows="4"].

REVIEW OF SYSTEMS:

The patient identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"][textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"][textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"][textarea memo="other" default="" rows="1"]
All other systems negative


MENTAL STATUS EXAM:
Patient presents as [select value="alert and oriented to |disoriented to |"][select value="person, place, and time|"][textarea rows="1"]. [select value="Recent and remote memory are intact|Recent memory is intact, although issues with remote memory include |Remote memory is intact, although issues with recent memory include |Issues with recent and remote memory are noted to be |"][textarea memo="additional information about memory" rows="3"]. [select value="Attention span and concentration are adequate|Difficulty with attention span and concentration are evidenced as "][textarea rows="2"]. Their language skills are [select value="adequate, |limited, |difficult to assess due to the degree of symptomatic presentation|"][select value="and consistent with education|and inconsistent with education|"][textarea rows="1"]. Their fund of knowledge is [select value="appropriate for stated age and education level|inappropriate for stated age and education level|difficult to assess due to symptomatic presentation|"][textarea rows="1"]. [select value="They are capable of abstraction|They display difficulty with abstraction|Assessment of abstraction ability difficult due to symptomatic presentation"][textarea rows="1"]. They appear to be [select value="their stated age|younger than their stated age|older than their stated age|"][textarea rows="1"]. They are [select value="well groomed|unkempt|"], [select value="appropriately dressed|inappropriately dressed|"][textarea rows="1"], [select value="in their own clothes|in hospital clothes|"][textarea rows="1"], with [select value="normal posture|slumped posture|rigid posture|"][textarea rows="1"]. Their behavior presents as [select value="calm|restless|agitated|irritable|anxious|impulsive|"][textarea rows="1"], and [select value="interactive|inattentive|withdrawn|"][textarea rows="1"][select value=" with good eye-contact| with intermittent eye-contact| with avoidant eye-contact"][textarea rows="1"]. [select value="Their gait presents as |They are incapable of ambulating|"][select value="normal|abnormal|unsteady|shuffling|spastic|"][textarea rows="1"]. [select value="Muscle strength and tone are |"][select value="equal for all limbs with free range of motion|"][textarea rows="1"]. Speech is [select value="a regular rate and rhythm|rapid|slow|"][textarea rows="1"][select value=", spontaneous|, appears prepared|"][select value=", fluid|, slurred|, monotone|, pressured|, laconic|"][select value=", normal volume|, quiet|, loud|"][textarea rows="1". Vocabulary is [select value="adequate|large|limited|difficult to assess due to symptomatic presentation|"][textarea rows="1"]. Thought processing and content present as [select value="adequate, |delayed, |"][select value="logical, |illogical, |"][select value="reality based|"][checkbox name="thoughts" memo="additional descriptors" value=""][conditional field="thoughts" condition="(thoughts).is('')"][checkbox value="disorganized|circumstantial|tangential|flight of ideas|loose association|perseveration|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"][/conditional][textarea rows="1"]. [select value="No evidence of hallucinations or delusions|Hallucinations/delusions characterized as "][textarea rows="1"]. [select value="No evidence of preoccupation with violence|They have a reoccupation with violence as evidenced by |"][textarea rows="1"]. [select value="They deny suicidal ideation|They report positive for suicidal ideation without intent|They report positive for suicidal ideation with intent |"][textarea rows="1"]. [select value="They deny homicidal ideation|They affirm homicidal ideation toward |"][textarea rows="1"]. Their judgment concerning everyday activities is [select value="good|fair|poor|impaired|"][textarea rows="1"]. Their insight concerning their psychiatric condition is [select value="good|fair|poor|impaired|"][textarea rows="1"].[checkbox name="hideRA" memo="Hide Risk Assessment Section" value=""][conditional field="hideRA" condition="(hideRA).isNot('')"]

RISK ASSESSMENT:

The patient is at a [select value="low|moderate|high"] acute and [select value="low|moderate|high"] chronic risk of suicide based on [select value="lack of current suicidal ideation|current suicidal ideation without a plan or intent|current suicidal ideation with a plan|"][text memo="other" value="20" and [select value="well|moderately|poorly"] treated psychiatric symptoms at this time. The patient has [checkbox value="no history of suicide attempts|a history of suicide attempts|a recent history of suicidal ideation|difficulty with supportive relationships|a minimal support system in the community"]. They present as [checkbox value="future oriented|with plans for self-improvement|having a strong sense of personal responsibility|ambivalent about personal outcomes|pessimistic about personal outcomes"]. [textarea memo="additional information about suicide risk factors" rows="3"] 
The patient is at a [select value="low|moderate|high"] acute and [select value="low|moderate|high"] chronic risk of violence based on [checkbox value="lack of current violent ideation|current violent ideation without a plan or intent|current violent ideation without a plan"] and [select value="well|moderately|poorly"] treated psychiatric symptoms at this time. The patient's history is reported to include [checkbox value="no history of agitation and violence|a recent history of agitation and violence|difficulty with mood regulation|but has improved significantly with treatment|has made moderate improvement with treatment|has made minimal improvement with treatment|has made no improvement with treatment"]. [textarea memo="additional information about violence risk factors" rows="3"][/conditional]