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. HPI: 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. R.O.S: 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: ***Denies*** 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***. Substances: 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: MENTAL STATUS EXAM: 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 EYE CONTACT: Good 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. THOUGHT CONTENT: No SI/HI 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 QUESTIONNAIRES (SEE ABOVE): BASIS-24: PHQ-9: PCL-M: 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: Formulation: 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."]
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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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