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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posted by: RUKnight[/html][/conditional]