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Psychiatric Review of Symptoms:
Depression: [select name="DepROS1” value="Denies any current depressive symptoms|Reports current depressive symptom of"] [checkbox name="depsx” value="sad mood|dysphoric mood|irritability|anhedonia|social withdrawal and isolation|crying spells|sleep disturbance|difficulty falling asleep, w/ delayed onset of sleep up to 1 hour|difficulty falling asleep, w/ delayed onset of sleep of 1 - 2 hours|difficulty falling asleep, w/ delayed onset of sleep greater than 2 hours|middle of night awakening|early morning awakening|moving or speaking so slowly that other people could have noticed|daytime fatigue|loss Of appetite|increased appetite|difficulty concentrating|decreased attention|increased anxiety|ruminative thoughts|feelings of worthlessness|excessive guilt|thoughts of death|mood symptoms are persistent and pervasive, varying little from day to day|depressed mood/sadness most of the time for 2-years or longer "]. [select value="Denies past history of depressive episodes.|Reports past history of depressive episodes."]

Mania: [select name="ManROS1” value="Denies any current manic symptoms.|Reports current manic symptoms of"] [checkbox name="mansx" value="distinct period of abnormally and persistently elevated, expansive or irritable mood|accompanied by persistently increased goal-directed activity or energy|mood disturbance and increased energy/activity has lasted at least one-week and is present most of the day, nearly every day|mood disturbance and increased energy/activity has lasted at least 4 consecutive days and is present most of the day|pressured speech|inflated self-esteem|grandiosity|decreased need for sleep|hyperverbosity|flight of Ideas|subjective racing thoughts|distractiblity|psychomotor agitation|high risk activities"][checkbox value=". Denies behaviors occurred solely in the context of substance abuse.| Reports majority of sx occurred in the context of substance abuse."][select value="Denies past history of manic/hypomanic episodes.|Endorses past history of manic/hypomanic episodes.| Endorses past history of manic/hypomanic episodes in context of substance abuse. No clear history of past manic/hypomanic episodes in the absence of co-occurring substance abuse."]

Psychosis: [select value="Denies any hallucinations or delusions.|"][select value="Denies past history of psychotic sx.|Endorses past history of psychotic sx.| Endorses past history of psychotic sx in context of substance abuse.
No clear history of psychosis in the absence of co-occurring substance abuse."]

MEDICAL HISTORY:[checkbox name="MEDHX" value="COPD|chronic back pain|CVA|obesity|hyperlipidemia|restless leg syndrome|type 2 diabetes mellitus|obstructive sleep apnea|hypertension "][textarea rows="3"]

[checkbox name="surghx" value="hysterectomy|appendectomy|total knee replacement-|option C"][textarea rows="3"]

FAMILY PSYCHIATRIC HISTORY: [checkbox name="variable_29" value="Denies|None reported|Adopted,family history unknown|No known history|Unable to obtain due to patient's current presentation, none per review of chart and collateral hx"][checkbox name="variable_1" value="Completed suicide- "][text name="variable_2" default=""] [checkbox name="variable_3" value="Suicide attempt- "][text name="variable_4" default=""] [checkbox name="variable_5" value="Depression- "][text name="variable_6" default=""] [checkbox name="variable_7" value="Anxiety- "][text name="variable_8" default=""] [checkbox name="variable_9" value="Bipolar- "][text name="variable_10" default=""] [checkbox name="variable_11" value="Schizophrenia- "][text name="variable_12" default=""] [checkbox name="variable_21" value="Psychosis- "][text name="variable_22" default=""] [checkbox name="variable_23" value="PTSD- "][text name="variable_24" default=""] [checkbox name="variable_25" value="ADHD- "][text name="variable_26" default=""] [checkbox name="variable_13" value="Alcohol abuse- "][text name="variable_14" default=""] [checkbox name="variable_15" value="Substance abuse- "][text name="variable_16" default=""] [checkbox name="variable_17" value="Psychiatric hospitalization- "][text name="variable_18" default=""] [checkbox name="variable_19" value="Dementia- "][text name="variable_20" default=""] [checkbox name="variable_27" value="Mental health problems, unknown/unclear type- "][text name="variable_28" default=""]
[textarea="variable_1" default="PSYCHIATRIC HISTORY:"]
Past Dx: [checkbox name="psychdx" value="No known formal diagnoses, treated in the past for|No known diagnoses|Unable to obtain, none noted upon review of available records|depression|anxiety|Major Depression|Bipolar Disorder|with psychotic features|“bipolar depression”|Schizophrenia|Schizoaffective Disorder|“bipolar schizophrenia”|Psychotic Disorder|Psychosis NOS|Generalized Anxiety Disorder|Postpartum Depression|Panic Disorder|hx of panic attacks|ADHD|ADHD-dx’d in adulthood|ADHD- dx’d in childhood|Mood Disorder|Adjustment Disorder|Somatoform Disorder|Somatic Symptom Disorder|hx of pseudoseizures|Factitious Disorder|”R/O Factitious Disorder”|Eating Disorder|Anorexia|Bulimia|Borderline Personality Disorder"]
Past Inpatient Tx: [checkbox name="variable_2" value="None|Unable to obtain, none noted on review of available records|No reported treatment on interview, however, chart review indicates |remote history of |past admission to |multiple-"][checkbox name="varMTMHI" memo="MTMHI" value=""] [conditional field=" varMTMHI" condition="(varMTMHI).is('')"][text size=65 default=" admission to MTMHI "][/conditional][checkbox name="varParthenon" memo="Parthenon" value=""] [conditional field="varParthenon" condition="(varParthenon).is('')"][text size=65 default="admission to Parthenon "][/conditional][checkbox name="varSkyline" memo="Skyline" value=""] [conditional field="varSkyline" condition="(varSkyline).is('')"][text size=65 default="admission to Skyline "][/conditional][checkbox name="varVanderbilt" memo="Vanderbilt" value=""] [conditional field="varVanderbilt" condition="(varVanderbilt).is('')"][text size=65 default="admission to Vanderbilt "][/conditional][checkbox name="varRollingHills" memo="Rolling Hills" value=""] [conditional field="varRollingHills" condition="(varRollingHills).is('')"][text size=65 default="admission to Rolling Hills "][/conditional][checkbox name="varTrustpoint" memo="Trustpoint" value=""] [conditional field="varTrustpoint" condition="(varTrustpoint).is('')"][text size=65 default="admission to Trustpoint "][/conditional][checkbox name="varMoccasinBend" memo="Moccasin Bend" value=""] [conditional field="varMoccasinBend" condition="(varMoccasinBend).is('')"][text size=65 default="admission to Moccasin Bend "][/conditional][checkbox name="varWesternState" memo="Western State" value=""] [conditional field="varWesternState" condition="(varWesternState).is('')"][text size=65 default="admission to Western State "][/conditional][checkbox name="varOther" memo="Other" value=""] [conditional field="varOther" condition="(varOther).is('')"][text size=65 default=""][/conditional]
Past Residential/Partial Hospitalization:[textarea name="variable_15" default=" none reported"]
Past Outpatient Tx: [checkbox name="past1" memo="Psychiatric provider for medication" value=""] [conditional field="past1" condition="(past1).is('')"][text size=65 default="Psychiatric provider for medication "][/conditional][checkbox name="past2" memo="Psychotherapy/Counseling" value=""] [conditional field="past2" condition="(past2).is('')"][text size=65 default="Psychotherapy/Counseling "][/conditional][checkbox name="past3" memo="Community Mental Health Center" value=""] [conditional field="past3" condition="(past3).is('')"][text size=65 default="Community Mental Health Center "][/conditional][checkbox name="past4" memo="Mental Health Case Management" value=""] [conditional field="past4" condition="(past4).is('')"][text size=65 default="Mental Health Case Management "][/conditional]
Suicide Attempts: [checkbox name="variable_99" value="Denies hx of attempts|No known history|Unable to obtain, none noted upon review of available records|Hx of intentional OD|hx of cutting wrist|hx of attempted hanging|hx of intentional poisoning|hx of attempt with gun|hx of attempt by jumping in front of car"][text name="suicatt" default=""]
Non-Suicidal Self Injurious Behx: [checkbox name="variable_18" value="Denies hx|No known hx|Unable to obtain, none noted upon review of available records|Hx of cutting for tension-release|Hx of|"]
Hx of Violence/Assaultive Behx: [checkbox name="assaulthx" value="Denies hx|None reported|Unable to obtain, none noted upon review of available record|Hx of"]
Past psychiatric medication trials include: [checkbox value="Has taken psych meds before, cannot recall name| Alprazolam (Xanax)| amitriptyline (Elavil)| amoxapine (Asenden)| aripiprazole (Abilify)| Aripiprazole (Abilify Maintena Injectable)| Aripiprazole lauroxil (Aristada Injectable)|asenapine (Saphris)|atomoxetine (Strattera)|benzotropine (Cogentin)| brexpiprazole (Rexulti )| bupropion (Wellbutrin)| buspirone (BuSpar)| carbamazepine (Tegretol)| clonidine for ADHD (Catapres)| chlordiazepoxide (Librium)| chlorpromazine (Thorazine)| citalopram (Celexa)| clomipramine (Anafranil)| clonazepam (Klonopin)| clorazepate (Tranxene)| clozapine (Clozaril)| diphenhydramine (Benadryl)| desipramine (Norpramin)| desvenlafaxine (Pristiq)|amphetamine and dextroamphetamine(Adderall)|Dexedrine)| dexmethylphenidate (Focalin)| diazepam (Valium)| donepezil (Aricept)|doxepin (Sinequan)| duloxetine (Cymbalta)| escitalopram (Lexapro)| folic acid| fluoxetine (Prozac)|fluoxetine + olanzapine (Symbyax)| fluphenazine (Prolixin)| fluphenazine (Prolixin Injectable)| fluvoxamine (Luvox)| gabapentin (Neurontin) for anxiety/mood| galantamine (Razadyne)| guanfacine for ADHD (Intuniv/Tenex)| haloperidol (Haldol)| Haldol Decanoate Injectable| hydroxyzine (Atarax/Vistaril)| imipramine (Tofranil)| L-methylfolate (Deplin)| lamotrigine (Lamictal)| lisdexamfetamine (Vyvanse)| lithium (Lithobid)| Lorazepam (Ativan)| loxapine (Loxitane)| lurasidone (Latuda)| maprotiline (Ludiomil)| melatonin (OTC)| memantine (Namenda)| mesoridazine (Serentil)| methylphenidate (Ritalin/Concerta/Metadate/Daytrana)|milnacipran (Savella)| mirtazapine (Remeron)| modafinil (Provigil)| molindone (Moban)| nefazodone (Serzone)| nortriptyline (Pamelor)| olanzapine (Zyprexa)| Olanzapine pamoate (Zyprexa Relprevv Injectable)| oxazepam (Serax)| oxcarbazepine (Trileptal)| Paliperidone (Invega Sustenna Injectable)| Paliperidone (Invega Trinza Injectable)| paroxetine (Paxil)| pemoline (Cylert)| perphenazine (Trilafon)| phenelzine (Nardil)| prazepam (Centrax)| prazosin (for nightmares)| prochlorperazine (Compazine)| protriptyline (Vivactil)| quetiapine (Seroquel)| risperidone (Risperdal)| Risperidone (Risperdal Consta Injectible)| rivastigmine (Exelon)| selegiline(Emsam)| sertraline (Zoloft)| temazepam (Restoril)| derealization (Mellaril)| topiramate (Topamax)| tranylcypromine (Parnate)| trazodone (Desyrel)| trifluoperazine (Stelazine)| trimipramine) or multiple)| valproic acid (Depakene/Depakote)| venlafaxine (Effexor)| vilazodone (Viibryd)| vortioxetine (Trintellix)| zaleplon (Sonata)| ziprasidone (Geodon)| zolpidem (Ambien)| zopiclone (Lunesta)|"]
[textarea rows="3"]

Relationship status: [select value="married||single|divorced|widowed"] [select value="|; not currently in relationship|; currently in relationship|for X years to current spouse|since XXX after X years of marriage"]; [select value="|no|1|2|3|4|5|6|7|"] [select value="|previous marriages|previous marriages ended in divorce|previous marriages, longest relationship ever was XX| x widowed and remarried"].
Children: [select value="none|1|2|3|4|5|6|7|"] [checkbox value="adult children|sons|son|daughters|daughter"][checkbox value="- living|"][checkbox value=", 1|, 2|, 3|, 4|, 5|, 6|, 7|"] [checkbox value="sons|son|daughters|daughter|children|child|"] [checkbox value="- deceased|- died in childhood|step-children|close with whom with step-children|not close with step-children"]
Living situation: [checkbox name="residence" value="home|apartment|group home|duplex|memory care unit|skilled nursing facility|homeless, most recently|assisted living facility|nursing home|apartment in senior housing|dormitory"][select value="|staying with friends/family|staying at Mission|sleeping on streets|in homeless encampment|staying at hotel|, lives with spouse/significant other|, lives alone|, lives with roommates|, lives with family|, lives with parents|, lives with "][textarea rows="1"].
Social Supports: [checkbox value="none|spouse/significant other|extended family|adult children|neighbors|friends|church members|hired caregivers|limited support system|limited local supports|limited positive supports"].
Education: [select value="0|1|2|3|4|5|6|7|8|9|10
|11|12|12+"] years of formal education, [checkbox value="dropped out before finishing, no GED|high school diploma|GED|undergraduate degree|master's degree|vocational training|some college|vocational degree/certification|doctorate|currently in school"]
Employment: [checkbox value="retired|currently unemployed|not looking for work|looking for work|in process of applying for disability|disabled due to psychiatric illness|disabled due to medical problems|homemaker|currently employed|on maternity leave|on medical leave of absence"].
Field/Occupation: [textarea rows="1"].
Source of Income: [checkbox value="none|unclear/unknown|disability|social security|unemployment|work|savings|retirement|family support|"][textarea rows="1"].
Military: [checkbox value="no reported history|denies history|retired|active|Army|Navy|Air Force|Marines|National Guard"][textarea rows="1"].
Legal History: active issues- [checkbox value="none reported|denies|reports active legal issues related to |currently on probation|currently on parole|upcoming court date"]; past history- [checkbox value="none reported| denies| previously incarcerated| past felony conviction|past history of violent offenses|denies past history of violent offenses|denies history of sex crimes|convicted sex offender"].
Trauma History: [checkbox name="sextrauma" value="denies history|none reported|sexual abuse in childhood|sexual abuse as adult|history of rape/sexual assault|physical abuse in childhood|physical abuse as adult|witnessed domestic violence in childhood|domestic violence in past relationship|emotional abuse in childhood|emotional abuse as adult|history of being bullied|natural disaster|violent crime |serious accident|serious medical event|combat|crime victim|near death experience|witnessed death"].
Psychiatric Review of Symptoms:
Depression: .






Past Dx:
Past Inpatient Tx: MTMHI Parthenon Skyline Vanderbilt Rolling Hills Trustpoint Moccasin Bend Western State Other
Past Residential/Partial Hospitalization:
Past Outpatient Tx: Psychiatric provider for medication Psychotherapy/Counseling Community Mental Health Center Mental Health Case Management
Suicide Attempts:
Non-Suicidal Self Injurious Behx:
Hx of Violence/Assaultive Behx:
Past psychiatric medication trials include:

Relationship status: ; .
Living situation: .
Social Supports: .
Education: years of formal education,
Employment: .
Source of Income: .
Military: .
Legal History: active issues- ; past history- .
Trauma History: .

Result - Copy and paste this output:

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