[textarea name="variable_1" default="Social Hx (Free Text)\nBorn Raised In \n & Grad Hs In"]

Tobacco Use [select name="variable_1" value="Non-Smoker|Ex-Smoker|Ex-User Of Moist Powdered Tobacco|Current Non Smoker But Past Smoking Hx Unknown|Light Cigarette Smoker (1-9 Cigs/Day)|Moderate Cigarette Smoker (10-19 Cigs/Day)|Heavy Cigarette Smoker (20-39 Cigs/Day)|Very Heavy Cigarette Smoker (40+ Cigs/Day)|Cigar Smoker|Pipe Smoker|Chews Tobacco|Chews Products Containing Tobacco|Snuff User"]Alcohol Use [select name="variable_1" value="Never|Less Than Monthly|Monthly Or Less|Weekly|Daily Or Almost Daily"]

Financial Resources
Financial Concerns:
Source Of Income:
Military:
Lives:
Works:
Housing Concerns:
Socioeconomic Status
Has Been [select name="variable_1" value="Unemployed |Employed"][text name="variable_1" default="#yrs"]
[textarea name="variable_1" default="Has Been Living \n Prior To That Was Living \n & Prior To That Was Living"]
Educational Level [select name="variable_1" value="Never Attended/No formal schooling|Kindergarten Only|1St Grade|2Nd Grade|3Rd Grade|4Th Grade|5Th Grade|6Th Grade|7Th Grade|8Th Grade|9Th Grade|10Th Grade|11Th Grade|12Th Grade, No Diploma|High School Graduate|Ged Or Equivalent|Some College, No Degree|Associate Degree Occupational, Technical, Or Vocational Program|Associate Degree Academic Program|Bachelor Degree (EG, Ba, Ab, Bs)|Master Degree (EG, Ma, Ms, Meng, Med, Msw, Mba)|Professional School Degree (Example Md, Dds, Dvm, Jd)|Doctoral Degree (Example Phd, Edd)–|Refused|Don't Know| Declined To Specify"]
Physical Activity
[select name="variable_1" value="Does Exercise Regularly|Does Not Exercise Regularly|unknown"]
sleep[select name="variable_1" value="Does Not Sleep Well|Does Sleep Well"]
Daytime Energy Is [select name="variable_1" value="Good|Average|Bad"]
Stress Level Is Rated [select name="variable_1" value="Not At All|Only Little|To Some Extent|Rather Much|Very Much|Declined To Specify|Mild|Moderate|Severe"]
Social Isolation & Connection
Exposure To Violence[select name="variable_1" value="Not Currently In Relationship w/ Someone Who Physically Hurts Or Threatens Them |Is Currently In Relationship w/ Someone Who Physically Hurts Or Threatens them"]
[textarea name="variable_1" default="describe"]
Relationship status
[checklist name="relationship status" value="Single Never Married |option B|option C"]
Children[text name="variable_1" default="#"]
Ages [text name="variable_1" default="#"]
Gender Identity | Sexual Orientation[select name="Gender Identity | Sexual Orientation" value="choice A|choice B|choice C"]

[textarea name="variable_1" default="Nutrition Hx"]
Past Medical Hx
Major Events
[text name="variable_1" default="x"]
Ongoing Medical Problems
[text name="variable_1" default="x"]
Preventive Care
PCP/ Clinic[checklist name="variable_1" value="No Preventive Care Recorded|San Francisco Health Plan|Sfhealthnetwork Primary Care|Castro-Mission Health Center|Potrero Hill Health Center|Beacon Health Options |Southeast Health Center|Chinatown Public Health Center|San Francisco Community Behavioral Health Services (Sfcbhs)"]
Medical Tx Needs(See
[link url="https://www.soapnote.org" memo="Pcp Med List "]Above)
Last Physical Exam Date [date name="variable_1" default="12/30/2019"]
Date Of Last Physical [date name="variable_1" default="12/30/2019"](If Not In Last 12 Months, Note If Referred To Pcp) [text name="variable_1" default="Referred To Pcp on:"]
Current Tx Team
[textarea name="variable_1" default="Primary Care Physician (Name, Address, Phone)\nMedical Doctor\nMedical Physician(S) \nMed Management Provider\nOther Providers"]
[checkbox name="variable_1" value="Does Not Have Pcp"]
Has Coordination Of Care w/ Other Providers Been Requested [select name="variable_1" value="yes|no|unknown|n/a"]
[text name="variable_1" default="describe"]
Drug Allergies/Adverse Reactions[select name="variable_1" value="yes|no|unknown|n/a"]
Major Medical Hospitalizations/Surgeries/Inpatient Procedures
[select name="variable_1" value="yes|no|unknown|n/a"][text name="variable_1" default="x"]
Surgical Hx
[textarea name="variable_1" default="No Surgical Hx Reported"]
Pyschotropic Meds[select name="variable_1" value="Past Medications Yes|Past Medications No"] Current Physical Condition/Illness
[textarea name="variable_1" default="Current Medical Dx \nNo Ongoing Medical Problems Recorded"]
[select name="variable_1" value="Accesses Medical Care As Needed (0)|Requires Education About Medical Condition(S) (1)|Needs Some Skill Building To Independently Access Medical Care (2)"]
[textarea name="variable_1" default="Does Not Smoke\nStopped Smoking\nCurrently Smokes
x Per Day"]
[textarea name="variable_1" default="Currently
Does Not Drink\nDrinks\nOccasionally"]

[textarea name="variable_1" default="Health Concerns \n Allergies\n Medications \n Family Health Hx"]
Presenting Illness
[1] - Has Participated In Counseling/Psychotherapy Services In Past
[select name="variable_1" value="No Previous Tx|Has Not Participated In Psychotherapy In Past| Yes|Has Participated In Psychotherapy In Past "](If Yes) Prior Tx
[checklist name="Past Tx" value="Psychiatric/Medication Management|Psychiatric Hospitalizations|Php/Partial Hospitalization|Outpatient Tx|Family Member Had Outpatient Psychotherapy|Individual & Group Mental Health Evaluation & Tx (Psychotherapy)|Rehab/Other Therapies|Behavioral Health Austism Spectrum Disorder, Aba Services|Crisis Intervention|Counseling From Therapist At Primary Care Clinic|Psychological Testing To Evaluate Mental Health Condition|Mental Health & Alcohol Use Screening & Counseling (Screening, Brief Intervention, Referral, & Tx, “Sbirt”)|Psychiatric Consultation|Individual & Group Mental Health|Recreational"]

[textarea name="variable_1" default="When\nw/ Whom"]
Interventions Used
[checklist name="variable_1" value="Cognitive Behavioral Tx|Exposure & Response Prevention Tx|Cognitive Processing Tx|Dialectical Behavior Tx Skills Training|Play Tx|Solution Focused|Problem Solving |Supportive Tx|Communication Skills |Grief Work |Coping|Skills/Relaxation Training |Crisis|Intervention |Parenting Skills |Family Tx"]
Experience/Outcome[text name="variable_1" default="?"]

Past Substance Use/ Past Sud Tx[checklist name="variable_1" value="No Hx Of Abuse|Active Abuse|Early Full Remission|Early Partial Remission|Sustained Full Remission| Remission Sustained Partial Remission"]
Substance Start Date[date name="variable_1" default="12/30/2019"]
Last Use [date name="variable_1" default="12/30/2019"]
[textarea name="variable_1" default="Amount
|Frequency | Rehab Program(S)|Etc"]
addiction Tx Needs
[select name="addiction Tx Needs" value="denies Addiction Hx, No Blackouts, No Duis, No 12 Steps, No Ivdu, No Hcv"]

Coping Skills
[checkbox name="variable_1" value="Positive Coping Skills|Motivated For Tx|Positive Problem Solving Skills"]
--- Support Network
[select name="variable_1" value="Lack Of Support Identified|Positive Support Identified"]
Current Barriers To Tx
[select name="variable_1" value="Current Apprehension To Engage In Structured Psychotherapy|Current Apprehension To Engage In Psychopharmaceutical Intervention|Excessive Demanding"]
First Started Seeing Psych
Age [text name="age" default="x"]
For [text name="years" default="?"]
Has Been To Psych Er/Ward
[text name="#" default="#x"]x
Attempted Suicide [text name="#" default="#x"]
Via
[text name="#" default="#x"]0
[textarea name="variable_1" default="Methods"] Trauma[text name="variable_1" default="?"]
[link url="https://www.soapnote.org" memo="Past Psychiatric Hx"]

Family Psychogenetics
no Known Family Psychiatric

Spirituality:


Legal Concerns:
[textarea name="variable_1" default="Criminogenic Tx Needs\npt Arrested X As Juvenile\n Arrested X As Adult"]

[textarea name="variable_1" default="Goals"]

Screenings/Interventions/Assessments
[checklist name="variable_1" value="Mental Status Examination|Phq-9|Gad-7, Aoq/Gds (Adult Version, Age 18+)|Phq-9 & Gad-7 (Child & Adolescent, Age 11-17)|Dsm-5 Level 1 Cross-Cutting Symptom Measure -- Adult Version
|Dsm-5 Level 1 Cross-Cutting Symptom Measure -- Child Age 11-17 Version
|Dsm-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 6–17"]