GENERAL: [select value="alert and oriented in all spheres|obtunded|disoriented"]
APPEARANCE: [select value="well kempt|poorly kempt|appropriately dressed|inappropriately dressed|appropriately groomed|inappropriately groomed"]
EYE CONTACT (observed): [select name="variable_1" value="≥ 3 seconds|Fleeting|None"]
INTEREST IN OTHERS (observed): [select name="variable_2" value="Initiates interaction with writer|Only passively responds to writer|No interest"]
POINTING SKILLS (observed): [select name="variable_3" value="Can Point/ Gesture to Object|Only Follows Point|None"]
LANGUAGE (reported and/or observed): [checkbox name="variable_4" value="Can Speak About Another Time Or Place|Single Words|Phrases (≤ 3 words)|Undeveloped Sentences|Nonverbal|Articulation Problem"]
PRAGMATICS OF LANGUAGE: [checkbox name="variable_5" value="Not impaired|Not applicable|Cannot manage turns or topics|Unvaried or odd intonation"]
ATTENTION: [select value="no difficulty with attention or concentration|had some attentional and concentration problems during the exam"]
REPETITIVE BEHAVIORS/ STEREOTYPY (reported and/or observed): [checkbox name="variable_6" value="None|Insists on Routines/ Compulsive-like behaviors |Motor stereotypy or vocal stereotypy|Echolalia|Stereotyped speech|Motor stereotypy or vocal stereotypy"]
UNUSUAL OR ENCOMPASSING PREOCCUPATIONS: [select name="variable_7" value="None|Present--:"]
UNUSUAL SENSITIVITIES (reported): [checkbox name="variable_1" value="None| Heightened Sensitivity|High Pain Threshold|Heightened Sensitivity|High Pain Threshold"]
COGNITION/MEMORY: [select value="normal|grossly intact|below average|above average"]. [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"]
RISK OF HARM TO SELF AND OTHERS: [select value="no current ideation or intent|denies an active sense of wanting to harm self or others|present but without intent or plan|resolved"].
Patient is currently assessed to be at [select value="low|moderate|high"] risk for self harm or harm to others as evidenced by ideation and behavior on today's exam.
There are 15 form elements.
Result - Copy and paste this output: