06-01-2020 v2

Patient Data

First Name: [text name="fname" default=""]
Last Name: [text name="lname" default=""]
Age: [text name="age" default=""]
Race: [text name="race" default=""]
Sex: [text name="sex" default=""]
Current City: [text name="currentcity" default=""]
Current State: [text name="currentstate" default=""]
Allergies: [select name="algy" value="NKA|ALGY"]
[conditional field="algy" condition="(algy).is('ALGY')"] Allergies: [text name="allergies" default=""][/conditional]
Primary Care Provider: [text name="currentpcp" default=""]

Caregiver

First Name: [text name="adult_fname" default=""]
Last Name: [text name="adult_lname" default=""]
Relationship to Patient: [text name="adult_id" default=""]

Education:
Current Grade: [text name="currentgrade" default=""]
School: [text name="currentschool" default=""]
IEP: [select name="IEP" value="Negative|Positive"][conditional field="IEP" condition="(IEP).is('Positive')"]
Status: [select name="IEP_status" value="Active|Inactive|Unknown"]
Reason: [text name="IEP_reason" default=""][/conditional]
504 Plan: [select name="504" value="Negative|Positive"][conditional field="504" condition="(504).is('Positive')"]
Status: [select name="504_status" value="Active|Inactive|Unknown"]
Reason: [text name="504_reason" default=""][/conditional]
Grade Retention: [select name="Retention" value="Negative|Positive"][conditional field="Retention" condition="(Retention).is('Positive')"]
Grade Retained: [text  name="Retention_reason" default=""][/conditional]

Military History: [select name="military_hx" value="Negative|Positive"][conditional field="military_hx" condition="(military_hx).is('Positive')"]
Details: [text name="military_hx_details" default=""].[/conditional]


Referring Source
First Name: [text name="referring_fname" default=""]
Last Name: [text name="referring_lname" default=""]
Credentialing: [select name="referring_cred" value="LPC|LSW|LCSW|LMSW|CMHP|MD|DO|NP|FNP|FMHNP|DNP|BS|BA|PsyD"]
Organization: [text name="referring_org" default="Ozark Center"]

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

Current Medications: [text name="currentmeds" default=""]
Past Psychiatric Medications: [text name=psych_past_meds" default=""]
Immunization Status: [select name="immunizations" value="Current|Delayed"]

Medical Problems: 
Asthma: [select name="asthma" value="Negative|Positive"]
Diabetes Mellitus: [select name="dm" value="Negative|Positive"]
Hypothyroidism: [select name="hypothyroid" value="Negative|Positive"]
Traumatic Brain Injury: [select name="TBI" value="Negative|Positive"]
Seasonal Allergies: [select name="seasonalallergies" value="Negative|Positive"]
Seizure: [select name="seizure" value="Negative|Positive"]

Surgical History: [select name="surg_hx" value="Negative|Positive"] 
[conditional field="surg_hx" condition="(surg_hx).is('Positive')"][textarea name="surg_hx_data" default="Patient has surgical history consisting of "].[/conditional]

Hospitalization History: [select name="hospital_hx" value="Negative|Positive"] 
[conditional field="hospital_hx" condition="(hospital_hx).is('Positive')"][textarea name="hospital_hx_data" default="Patient has hospitalization history consisting of "].[/conditional]

Symptom Onset Age: [text name="age_symptoms_first" default=""]
Symptom Description: 
[textarea name="hpi_symptom_onset" default=""]



Sleep: [select name="hpi_sleep" value="adequate|disruptive sleep|sleep onset Insomnia|excessive|inverted sleep pattern|with normal limits adjusted for age"]
Appetite: [select name="hpi_appetite" value=" adequate|low|excessive|variable|within normal limits"]
Energy: [select name="hpi_energy" value="adequate|low|excessive|variable|within normal limits"]
Self-Esteem: [select name="hpi_energy" value="adequate|low|developing|dimming|excessive|variable|within normal limits"]

Substance-Use History: [select name="substance_hx" value="Negative|Positive"]
[conditional field="substance_hx" condition="(substance_hx).is('Positive')"]

Primary Substance: [select name="substance_hx_substance-1_type" value="Alcohol|Cannabis|Tobacco|Methamphetamine|Cocaine|Crack|Heroine|Opiates|Amphetamine|Nicotine|Benzodiazepines|Stimulants"] 
Age of First Use: [text name="substance_hx_substance-1_firstuse_age" default=""]
Current Use: [select name="substance_hx_substance-1_current-use" value="-|Negative|Positive"]
Frequency/Amount/Context: 
[textarea name="substance_hx_substance-1_details" default=""] [/conditional]
[conditional field="substance_hx_substance-1_current-use" condition="(substance_hx_substance-1_current-use).is('Negative')"]Age of Last Use: [text name="substance_hx_substance-1_lastuse_age" default=""][/conditional]

[conditional field="substance_hx" condition="(substance_hx).is('Positive')"]

Secondary Substance-Use History: [select name="substance_hx_substance_2" value="Negative|Positive"]

Secondary Substance: [select name="substance_hx_substance-2_type" value="None|Alcohol|Cannabis|Tobacco|Methamphetamine|Cocaine|Crack|Heroine|Opiates|Amphetamine|Nicotine|Benzodiazepines|Stimulants|Other"] 
Age of First Use: [text name="substance_hx_substance-2_firstuse_age" default=""]
Current Use: [select name="substance_hx_substance-2_current-use" value="-|Negative|Positive"]
Frequency/Amount/Context: 
[textarea name="substance_hx_substance-2_details" default=""] [/conditional]
[conditional field="substance_hx_substance-2_current-use" condition="(substance_hx_substance-2_current-use).is('Negative')"]Age of Last Use: [text name="substance_hx_substance-2_lastuse_age" default=""][/conditional]







Global Functioning Axis: [text name="gaf_score" default=""]




Medications, Post-Session: 
[textarea name="medications_post-session" default=""]











Identifying Data/Chief Complaint: [var name="fname"] [var name="lname"] is a [var name="age"] year old [var name="race"] [var name="sex"] presenting for initial assessment and pharmacologic management of [var name="dx"]. Patient's [var name="adult_id"], [var name="adult_fname"] [var name="adult_lname"], brought [var name="fname"] for evaluation and lives in [var name="currentcity"], [var name="currentstate"]. Patient referred by [var name="referring_fname"] [var name="referring_lname"], [var name="referring_cred"] from [var name="referring_org"] with a chief complaint of "[var name="cc"]".

History of Present Illness: [var name="fname"] [var name="lname"] is a [var name="age"] year old [var name="race"] [var name="sex"] presenting for initial assessment and pharmacologic management of [var name="dx"]. Patient's [var name="adult_id"], [var name="adult_fname"] [var name="adult_lname"], brought [var name="fname"] for evaluation and lives in [var name="currentcity"], [var name="currentstate"]. Patient was referred as mentioned with the above chief complaint. [var name="fname"]'s [var name="adult_id"] first noticed symptoms when [conditional field="sex" condition="(sex).is('male')"]he[/conditional][conditional field="sex" condition="(sex).is('female')"]she[/conditional] was a[conditional field="age_symptoms_first" condition="(age_symptoms_first).is('8')||(age_symptoms_first).is('11')||(age_symptoms_first).is('18')"]n[/conditional] [var name="age_symptoms_first"] year old and these consisted of "[var name="hpi_symptom_onset"]"

Psychiatric ROS: 

Psychiatric History: 

Substance-Use History: [conditional field="substance_hx" condition="(substance_hx).is('Negative')"]There are no reports of any recent alcohol, tobacco, or illicit substance-use.[/conditional][conditional field="substance_hx" condition="(substance_hx).is('Positive')"]Patient has a history of some substance-use. There are reports of [var name="substance_hx_substance-1_type"]-use starting at [var name="substance_hx_substance-1_firstuse_age"] years old[/conditional][conditional field="substance_hx_substance-1_current-use" condition="(substance_hx_substance-1_current-use).is('Positive')"] and patient indicated current use described as, "[var name="substance_hx_substance-1_details"]"[/conditional][conditional field="substance_hx_substance-1_current-use" condition="(substance_hx_substance-1_current-use).is('Negative')"] and patient last used at [var name="substance_hx_substance-1_lastuse_age"] years old. History of the above described as, "[var name="substance_hx_substance-1_details"]".[/conditional]

General Medical History: [conditional field="algy" condition="(algy).is('NKA')"]Patient reported no known allergies.[/conditional][conditional field="algy1" condition="(algy).is('ALGY')"]Patient reported allergies consisting of [var name="allergies"].[/conditional] [conditional field="immunizations" condition="(immunizations).is('Current')"]Patient’s immunizations are up to date. [/conditional][conditional field="immunizations" condition="(immunizations).is('Delayed')"]Patient’s immunizations are not up to date and are delayed (See HPI for further remark). [/conditional][conditional field="currentmeds" condition="(currentmeds).is('')"]Patient does not currently take any medication.[/conditional][conditional field="currentmeds1" condition="(currentmeds).isGreater('0')"]Patient is currently prescribed [var name="currentmeds"].[/conditional] [conditional field="surg_hx" condition="(surg_hx).is('Negative')"][var name="fname"] does not have any prior surgical history.[/conditional][conditional field="surg_hx" condition="(surg_hx).is('Positive')"][textarea name="surg_hx_data" default="Patient has surgical history consisting of "].[/conditional] [conditional field="hospital_hx" condition="(hospital_hx).is('Negative')"][var name="fname"] does not have any prior hospitalization history.[/conditional][conditional field="hospital_hx" condition="(hospital_hx).is('Positive')"][textarea name="hospital_hx_data" default="Patient has hospitalization history consisting of "].[/conditional] 

Developmental History: 

Social History: 

Occupation/Military: Patient is a[conditional field="currentgrade" condition="(currentgrade).is('8th')||(currentgrade).is('11th')"]n[/conditional] [var name="currentgrade"] grade student attending [var name="currentschool"][conditional field="IEP|504|Retention" condition="(IEP).is('Negative')&&(504).is('Negative')&&(Retention).is('Negative')"] without any history of having an IEP, 504 Plan or any grade level retention.[/conditional][conditional field="IEP|504|Retention" condition="(IEP).is('Positive')&&(504).is('Negative')&&(Retention).is('Negative')"] and has an IEP for [var name="IEP_reason"] without any history of having a 504 Plan or any grade level retention.[/conditional][conditional field="IEP|504|Retention" condition="(IEP).is('Positive')&&(504).is('Positive')&&(Retention).is('Negative')"] with an IEP for [var name="IEP_reason"] and a 504 Plan for [var name="504_reason"]. Patient does not have any history of grade-level retention.[/conditional][conditional field="IEP|504|Retention" condition="(IEP).is('Positive')&&(504).is('Positive')&&(Retention).is('Positive')"] with an IEP for [var name="IEP_reason"] and a 504 Plan for [var name="504_reason"]. Patient has a history of grade-level retention for the [var name="Retention_reason"] grade.[/conditional][conditional field="IEP|504|Retention" condition="(IEP).is('Negative')&&(504).is('Positive')&&(Retention).is('Positive')"] without history of having an IEP. There are reports of having a 504 Plan for [var name="504_reason"] and a history of grade-level retention for the [var name="Retention_reason"] grade.[/conditional][conditional field="IEP|504|Retention" condition="(IEP).is('Negative')&&(504).is('Negative')&&(Retention).is('Positive')"] without any history of having an IEP or 504 Plan. [var name="fname"] has a history of grade-level retention for the [var name="Retention_reason"] grade.[/conditional][conditional field="IEP|504|Retention" condition="(IEP).is('Negative')&&(504).is('Positive')&&(Retention).is('Negative')"] without any history of having an IEP or grade-level retention. [var name="fname"] has a 504 plan for [var name="504_reason"].[/conditional]

Legal History: 

Family History: 

Review of Systems:

Mental Status Exam: 

Functional Assessment: GAF Score: [var name="gaf_score"]

Diagnostic Tests: 

Interpretive Summary: 

Current medications:

[var name="medications_post-session"]

Diagnosis: