Military Intake Note

ID: [text default="20/000-00-0000"] Date: [date]

Name: [textarea rows=1 default="Last Name, First Name, Middle Initial" Age: [text] years old

Rank: [text]  Service: U.S. [select value="Army|Navy|Air Force|Marines"]

Contact info: Cell: [text] Work: [text] Home: [text]

Street Address: [textarea]

E-mail: [text]

Command Contact Info: [textarea rows=3]

Referral Source: [textarea rows=1 default="***Dr. X/Self-referral***"]

[textarea columns=80 rows=25 default="SUBJECTIVE:
CC: Sometimes I find myself getting angry for no reason, and getting frustrated over little things.
This is a ***26***yo male ***AD/Family Member/Civilian USA/USN/USAF ***E-4*** , with a history of ***depression/anxiety/alcohol/substance abuse***, here today by ***referral from/self-referral*** for ***
He denies any thoughts of self harm, or harm to others.


Psychiatric review of symptoms noted above and medical review of symptoms otherwise negative.
Past Psych Hx:

See HPI above

He ***reports/denies any*** previous inpatient admissions, suicide attempts, or self-mutilating behaviors in the past.

He has previously been prescribed *** with *** results.

He has worked with a therapist in the past for ***

Fam Psych hx:

He denies any significant family psych history, including schizophrenia, bipolar disorder, depression, anxiety, alcohol or substance abuse, or attempted/completed suicides

Medical & Surgical Hx:


Current Medications:

Allergies: ***NKDA***

Developmental hx:

The ***patient/SM*** was born and raised in. He denies any developmental delays and progressed along with his peers. He graduated high school ***on time/early/late*** and was active in ***. He ***attended/did not attend*** college resulting in ***

Military hx:

***Patient/SM*** joined the ***Army/Navy/Air Force*** in ***. His ***MOS/AOC*** is ***, which is a ***. Deployment history includes ***. During deployment, he reports ***TBI/PTSD***

Social hx:

He lives with ***. They have ***#*** children. He reports having ***lots of/minimal*** friends, which he feels are a ***strong/weak*** social support system. He reports being close with his family, which includes ***mom/dad/older sis, etc***.


He ***admits/denies*** using ***alcohol/illicit substances/tobacco ***frequency***.

Suicide Risk Factors: He appears to be a ***low/mod/high*** risk for suicide at this time."]

Safety Assessment:
Non-modifiable risk factors
[select value="no|YES"] History of suicide attempts
[select value="no|YES"] Chronic psychiatric disorder
[select value="no|YES"] Recent psychiatric hospitalization
[select value="no|YES"] History of abuse/trauma
[select value="no|YES"] Chronic physical illness
[select value="no|YES"] Family history of suicidality
[select value="no|YES"] Unmarried status
[select value="no|YES"] Recent significant loss
[select value="no|YES"] Significant life transitions
Modifiable risk factors
[select value="no|YES"] Treatment compliance
[select value="no|YES"] Hopelessness
[select value="no|YES"] Psychic pain/anxiety
[select value="no|YES"] Functional turmoil/acute event
[select value="no|YES"] Sleep disturbance
[select value="no|YES"] Self-esteem
[select value="no|YES"] Impulsivity
[select value="no|YES"] Substance abuse
[select value="no|YES"] Positive coping skills
[select value="no|YES"] Access to weapons
Protective factors
[select value="no|YES"] Responsibility to family member(s)
[select value="no|YES"] Frustration tolerance
[select value="no|YES"] Resilience
[select value="no|YES"] Capacity for reality testing
[select value="no|YES"] Patient’s amenability to treatment
[select value="no|YES"] Social support
Risk Level based on the above data:
[select value="Minimal|Moderate|Severe"] Risk
[textarea default="There ***do/do not*** appear to be ***any*** safety concerns at this time. Risks are noted above. Protective factors include: ***"]
[textarea columns=80 rows=25 default="OBJECTIVE:


APPEARANCE: ***White/African American/Hispanic*** male that appears his stated age, tall height and average weight for a male his age, no physical deformities. His dress was appropriate attire for the interview, ACUs. His gait and motor coordination were normal, posture erect.

RAPPORT: Open and friendly, candid and cooperative


THOUGHT PROCESS: Linear, logical, and goal-directed thought. Could recall the plot of a favorite movie or book logically; Easy to understand his line of reasoning; No loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization.


PERCEPTIONS: No AVH, ***does/does not*** appear to be responding to internal stimuli.

SPEECH: Normal rate and volume, good enunciation quality, no problems expressing self, no misuse of words in a low-vocabulary-skills way, no misuse of words in a bizarre-thinking-processes way.

MOOD: ”***I'm having problems controlling my anger***.”

AFFECT: Pt with full range of affect. Able laugh appropriately.

JUDGEMENT: ***Poor/Fair/Good/Excellent***

INSIGHT: ***Poor/Fair/Good/Excellent***

IMPULSIVITY: ***Low/Moderate/High***, by history

COGNITION: Grossly Intact





Adult ADHD Self-Report Symptoms Scale:"]
[textarea columns=80 rows=25 default="ASSESSMENT:

This is a ***26***yo ***AD/Family Member/Civilian ***USA/USN/USAF*** ***E-4*** male, with a history of ***depression/anxiety/alcohol/substance abuse***, here today by ***referral from/self-referral*** for ***

Biologically, ***

Psychologically, ***

Socially, ***

Axis I: ***Sexual identity disorder***

Axis II: ***

Axis III: ***Apnea, chronic pain, fibromyalgia***

Axis IV: ***Axes I & II/work stressors***

Axis V: ***70***
[textarea columns=80 rows=25 default="PLAN:


1. Will follow up with pt on *** at ***

2. ***No medications prescribed at this time/Will begin...***

3. ***Service Member/patient to continue therapy with...***

4. Safety assessment performed and there ***are/are no*** acute safety concerns at this time, suicide risk is low. The ***SM/patient*** denies any SI/HI/AVH and agrees to report to the German ER/call the MP’s/or call crisis line if these symptoms arise outside of the Behavioral clinic’s normal business hours.

TIME spent face-to-face during the session is 90 min.

MEDICATIONS were reviewed and reconciled accordingly.

Reviewed INTAKE paperwork.

The patient ***does/does not*** have PAIN associated with this visit.

The patient ***does/does not*** have NUTRITIONAL concerns associated with this visit.

The patient ***does/does not*** report nor demonstrate BARRIERS TO LEARNING. Primary language is ***English/Spanish/German***.

Patient ***does/does not*** request further information.

The patient was EDUCATED about both diagnosis and treatment.

Patient VERBALIZED AN UNDERSTANDING of the diagnosis and treatment plan.

Today’s visit ***is/is not*** related to a past DEPLOYMENT.

Patient ***admits/denies*** use of TOBACCO products."]
ID: Date:

years old

Rank: Service: U.S.

Contact info: Cell: Work: Home:

Street Address:


Command Contact Info:

Referral Source:

Safety Assessment:
Non-modifiable risk factors
History of suicide attempts
Chronic psychiatric disorder
Recent psychiatric hospitalization
History of abuse/trauma
Chronic physical illness
Family history of suicidality
Unmarried status
Recent significant loss
Significant life transitions
Modifiable risk factors
Treatment compliance
Psychic pain/anxiety
Functional turmoil/acute event
Sleep disturbance
Substance abuse
Positive coping skills
Access to weapons
Protective factors
Responsibility to family member(s)
Frustration tolerance
Capacity for reality testing
Patient’s amenability to treatment
Social support
Risk Level based on the above data:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.65, 43 form elements, 110 boilerplate words, 6 text boxes, 9 text areas, 1 dates, 27 drop downs, 43 total clicks
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