Cree’s form

Date: [date name="date" default=""] Time: [text name="time" default=""]

Telemedicine Consent

*The patient consents to treatment and consultation via telemedicine (remote video visit); the patient was informed of the limitations of telemedicine;oral and written consent was received*

F\

HISTORY OF PRESENT ILLNESS:

Age of symptom onset: [select name="symptom_onset_age" value="Childhood|Adolescence|Adulthood"]
History of impairment and treatment: [textarea name="impairment_history" default=""]
Current symptoms and functional impairments: [textarea name="current_symptoms" default=""]

PSYCHIATRIC REVIEW OF SYSTEMS:
ADHD:
ASRS- A Evaluation Score: [select name="asrs_a_score" value="0|1|2|3|4|5|6|7|8|9"]
Patient [select name="ADHD inattentive" value="|ENDORSES|DENIES"] inattentive symptoms of ADHD:
[checkbox name="inattentive_symptoms" value="Problems following through on directions/unfinished tasks|Difficulty with organization; often forgetful|Reluctance to engage in tasks requiring sustained attention|Failing to give close attention to details/careless mistakes|Difficulty sustaining attention|Problems listening when spoken to directly|Misplaces things necessary for tasks and activities|Easily distracted by extraneous stimuli"]

Patient [select name="ADHD hyperactive" value="|ENDORSES|DENIES"] hyperactivity symptoms of ADHD:
[checkbox name="hyperactivity_symptoms" value="Fidgets/squirms|Always on the go, driven by a motor|Often leaves seat when remaining seated is expected|Restlessness|Trouble engaging in leisure activities|Talks excessively|Blurts out answers/completes other people sentences|Difficulty waiting their turn|Interrupts or intrudes on others"]

DEPRESSION:
PHQ-9 Score: [select name="phq9_score" value="0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27"]

Patient [select name="MDD" value="|ENDORSES|DENIES"] symptoms of DEPRESSION:
[checkbox name="depression_symptoms" value="Loss of interest in pleasurable activities|Sad mood and feelings of hopelessness|Problems with energy|Feelings of guilt or worthlessness|Problems with concentration|Psychomotor disturbance"]

ANXIETY:
GAD-7 Score: [select name="gad7_score" value="0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21"]
Patient [select name="GAD" value="|ENDORSES|DENIES"] symptoms of GENERALIZED ANXIETY:
[checkbox name="anxiety_symptoms" value="Excessive worrying throughout the day|Feeling nervous and on edge|Constant worry|Racing thoughts|Trouble relaxing|Feeling restless|Irritability|Feelings of impending doom"]

Triggers: [textarea name="anxiety_triggers" default=""]

PANIC:
Patient [select name="panic" value="|ENDORSES|DENIES"] symptoms of PANIC ATTACKS:

Triggers: [textarea name="panic_triggers" default=""]
Frequency: [select name="panic_frequency" value="Daily|Weekly|Monthly|Rarely"]

INSOMNIA:
Sleep routine: [textarea name="sleep_routine" default=""]
Average hours of sleep per night: [select name="sleep_hours" value="1|2|3|4|5|6|7|8|9|10|11|12"]

Patient [select name="Insomnia" value="|ENDORSES|DENIES"] symptoms of INSOMNIA: 
[checkbox name="insomnia_details" value="Difficulty falling asleep|Difficulty staying asleep"]

MANIA/HYPOMANIA:
Patient [select name="Mania" value="|ENDORSES|DENIES"] symptoms of MANIA/HYPOMANIA: [select name="mania_symptoms" value="|ENDORSES|DENIES"]
[checkbox name="mania_details" value="Abnormal or elevated mood|Expansive or irritable mood|Marked increase in energy|Reckless/impulsive behaviors|Increased money spending|Hypersexuality|Decreased need for sleep|Racing thoughts|Increased/pressured speech"]

OTHER:
Patient also [select name="other" value="|ENDORSES|DENIES"]S any history of, or current concerns relating to:
[checkbox name="other_concerns" value="Trauma or Abuse|Intrusive thoughts|Paranoidor delusional thoughts|Psychosis, A/V hallucinations|Cognitive alterations or acute decline in memory|Eating Disordered Behaviors|Ritualistic or obsessive/compulsive thoughts or behaviors"]

PSYCHIATRIC HISTORY AND SAFETY ASSESSMENT:
Past hx of suicide attempts: [select name="past_suicide_attempts" value="Yes|No"]

Current suicidal thoughts/ideation: [select name="current_suicidal_thoughts" value="Yes|No"]

Suicidal intention/plan: [select name="suicidal_intention_plan" value="Yes|No"]

Access: [select name="access_to_lethal_means" value="Yes|No"]

Self-injurious behaviors (ie, cutting): [select name="self_injurious_behaviors" value="Yes|No"]

Hx of violence / homicidal ideations with plan or intent: [select name="violence_homicidal_ideations" value="Yes|No"]

Previous Psychiatric medication trials: [textarea name="previous_psych_med_trials" default=""]

Past Psychiatric Hospitalizations: [textarea name="past_psych_hospitalizations" default=""]

Past or Current Therapy/ Counseling: [textarea name="past_current_therapy" default=""]

MEDICAL HISTORY:
Current Height: [text name="current_height" default=""]

Current Weight: [text name="current_weight" default=""]

PCP name: [text name="pcp_name" default=""]

Last PCP appointment: [date name="last_pcp_appointment" default=""]

ROS:
Medical conditions reported by the patient: [textarea name="medical_conditions" default=""]

Drug Allergies: [textarea name="drug_allergies" default=""]

Current Daily Medications: [textarea name="current_daily_medications" default=""]

Female patients:
Currently Pregnant or Family Planning: [select name="pregnant_family_planning" value="Yes|No"]
Currently Breastfeeding: [select name="breastfeeding" value="Yes|No"]
Currently using some sort of Birth control method: [select name="birth_control" value="Yes|No"]

FAMILY HISTORY:
Pertinent Family History of Mental Health Conditions: [textarea name="family_history_mental_health" default=""]
Pertinent Family History of Medical Conditions: [textarea name="family_history_medical_conditions" default=""]

SOCIAL/ LIFESTYLE :
Housing: [textarea name="housing" default=""]

Currently lives with: [textarea name="currently_lives_with" default=""]

Relationships/ Support:
Partner: [text name="partner" default=""]
Children: [text name="children" default=""]
Family/ Friends: [textarea name="family_friends_support" default=""]

Career/School:
Occupation/ Major: [textarea name="occupation_major" default=""]
Work/ School hours: [textarea name="work_school_hours" default=""]

Legal or Financial Issues: [textarea name="legal_financial_issues" default=""]

Physical Activity/ Hobbies: [textarea name="physical_activity_hobbies" default=""]

Diet/ Nutrition/ Appetite Issues: [textarea name="diet_nutrition_appetite_issues" default=""]

Any New or Worsening Stressors: [textarea name="new_worsening_stressors" default=""]

SUBSTANCE USE:
Caffeine: [textarea name="caffeine_use" default=""]

Alcohol: [textarea name="alcohol_use" default=""]

Nicotine products: [textarea name="nicotine_use" default=""]

Marijuana: [textarea name="marijuana_use" default=""]

Any other substances including, but not limited to: sedati stimulants; opioids; hallucinogens; dissociatives; inhalants; club drugs: [textarea name="other_substance_use" default=""]

Hx of Substance Abuse Treatment: [textarea name="substance_abuse_treatment" default=""]

SUMMARY:
Clinician's summary of the patient's presenting symptoms and concerns: [textarea name="clinician_summary" default=""]

ASSESSMENT:
[textarea name="assessment" default=""]

**ASSESSMENT:
Patient is an AGE yo GENDER with past psychiatric history of presenting with concerns for ADHD.
presenting for transfer of care and continuation of medication management.

Per the patient’s report, review of symptoms, screening measures, and this provider’s thorough assessment, the patient has met the DSM-V diagnostic criteria for The patient reports their symptoms are causing maladaptive functioning and impairment across their interpersonal, occupational, and social
settings. The patient has been unable to alleviate these symptoms on their own through non-pharmacological interventions and are in need of medication management which will require continued treatment. Medication choices were discussed and provider and patient agree that The patient currently denies suicidal or homicidal ideation.

DIAGNOSTIC IMPRESSIONS:
[textarea name="diagnostic_impressions" default=""]

PLAN:

Psychoeducation and normalization of symptoms:
[textarea name="plan_psychoeducation" default=""]

Treatment goals and recommendations:
[textarea name="plan_treatment_goals" default=""]

Pharmacotherapy options and rationale (if indicated):
[textarea name="plan_pharmacotherapy" default=""]

Psychotherapy options and rationale (if indicated):
[textarea name="plan_psychotherapy" default=""]


Follow-up schedule:
[textarea name="plan_follow_up_schedule" default=""]

**Provider and patient can communicate asynchronously via the "Consultations" tab on Done. website. Patients can also follow up as needed with the provider by scheduling a video follow-up appointment. This Provider would AT LEAST need the patient to schedule a video follow-up appointment every 6 months in order to closely monitor their progress and continue to safely provide medication management.**


Additional recommendations:
[textarea name="plan_additional_recommendations" default=""]

********************* Additional Notes ******************
Patient’s preferred Pharmacy-verified and updated in the chart. ID verification verified Side Effect Education:
Re: Stimulants: Side effects of stimulants can include decreased appetite, insomnia particularly if taken too late in the day, dry mouth, tics, tremor,agitation or psychosis, changes in libido, elevated heart rate, and blood pressure. Dangerous side effects could include psychotic sx, seizures, cardiovascular events and
arrhythmia. There is an increased risk of arrhythmia or cardiovascular problems in persons with a personal history of cardiac disease or stroke or a family history of cardiac or stroke at an early age or sudden death. There is a risk of worsening or side effects of glaucoma, vision changes or eye pain. Stimulants have a risk of dependency and addiction.People can develop tolerance necessitating increases in doses. if possible, it is helpful to take the medication only on days in which it is needed Informed Consent:
Psychoeducation provided as to the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan.

Provider and patient discussed the danger of misuse of stimulant medications and the patient agreed to take medication only for themselves. The patient is to contact our office with any questions, concerns, adverse side effects, or changes in mental health status. The patient is advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans. The patient is advised against using alcohol and/or illicit substances while on psychotropic medication due to the risk of negative interactions and is aware doing so will be at his/her own risk. It is recommended that the patient should discuss this diagnosis and treatment plan with their PCP as well, as we don't want to have overriding and/or conflicting plans. The patient is encouraged to follow up with PCP for routine health and lab monitoring and maintenance.The patient verbalizes understanding, agrees to this treatment plan,and agrees to coordinate care as needed.


Date: Time:

Telemedicine Consent

*The patient consents to treatment and consultation via telemedicine (remote video visit); the patient was informed of the limitations of telemedicine;oral and written consent was received*

F\

HISTORY OF PRESENT ILLNESS:

Age of symptom onset:
History of impairment and treatment:

Current symptoms and functional impairments:


PSYCHIATRIC REVIEW OF SYSTEMS:
ADHD:
ASRS- A Evaluation Score:
Patient inattentive symptoms of ADHD:


Patient hyperactivity symptoms of ADHD:


DEPRESSION:
PHQ-9 Score:

Patient symptoms of DEPRESSION:


ANXIETY:
GAD-7 Score:
Patient symptoms of GENERALIZED ANXIETY:


Triggers:


PANIC:
Patient symptoms of PANIC ATTACKS:

Triggers:

Frequency:

INSOMNIA:
Sleep routine:

Average hours of sleep per night:

Patient symptoms of INSOMNIA:


MANIA/HYPOMANIA:
Patient symptoms of MANIA/HYPOMANIA:


OTHER:
Patient also S any history of, or current concerns relating to:


PSYCHIATRIC HISTORY AND SAFETY ASSESSMENT:
Past hx of suicide attempts:

Current suicidal thoughts/ideation:

Suicidal intention/plan:

Access:

Self-injurious behaviors (ie, cutting):

Hx of violence / homicidal ideations with plan or intent:

Previous Psychiatric medication trials:


Past Psychiatric Hospitalizations:


Past or Current Therapy/ Counseling:


MEDICAL HISTORY:
Current Height:

Current Weight:

PCP name:

Last PCP appointment:

ROS:
Medical conditions reported by the patient:


Drug Allergies:


Current Daily Medications:


Female patients:
Currently Pregnant or Family Planning:
Currently Breastfeeding:
Currently using some sort of Birth control method:

FAMILY HISTORY:
Pertinent Family History of Mental Health Conditions:

Pertinent Family History of Medical Conditions:


SOCIAL/ LIFESTYLE :
Housing:


Currently lives with:


Relationships/ Support:
Partner:
Children:
Family/ Friends:


Career/School:
Occupation/ Major:

Work/ School hours:


Legal or Financial Issues:


Physical Activity/ Hobbies:


Diet/ Nutrition/ Appetite Issues:


Any New or Worsening Stressors:


SUBSTANCE USE:
Caffeine:


Alcohol:


Nicotine products:


Marijuana:


Any other substances including, but not limited to: sedati stimulants; opioids; hallucinogens; dissociatives; inhalants; club drugs:


Hx of Substance Abuse Treatment:


SUMMARY:
Clinician's summary of the patient's presenting symptoms and concerns:


ASSESSMENT:


**ASSESSMENT:
Patient is an AGE yo GENDER with past psychiatric history of presenting with concerns for ADHD.
presenting for transfer of care and continuation of medication management.

Per the patient’s report, review of symptoms, screening measures, and this provider’s thorough assessment, the patient has met the DSM-V diagnostic criteria for The patient reports their symptoms are causing maladaptive functioning and impairment across their interpersonal, occupational, and social
settings. The patient has been unable to alleviate these symptoms on their own through non-pharmacological interventions and are in need of medication management which will require continued treatment. Medication choices were discussed and provider and patient agree that The patient currently denies suicidal or homicidal ideation.

DIAGNOSTIC IMPRESSIONS:


PLAN:

Psychoeducation and normalization of symptoms:


Treatment goals and recommendations:


Pharmacotherapy options and rationale (if indicated):


Psychotherapy options and rationale (if indicated):



Follow-up schedule:


**Provider and patient can communicate asynchronously via the "Consultations" tab on Done. website. Patients can also follow up as needed with the provider by scheduling a video follow-up appointment. This Provider would AT LEAST need the patient to schedule a video follow-up appointment every 6 months in order to closely monitor their progress and continue to safely provide medication management.**


Additional recommendations:


********************* Additional Notes ******************
Patient’s preferred Pharmacy-verified and updated in the chart. ID verification verified Side Effect Education:
Re: Stimulants: Side effects of stimulants can include decreased appetite, insomnia particularly if taken too late in the day, dry mouth, tics, tremor,agitation or psychosis, changes in libido, elevated heart rate, and blood pressure. Dangerous side effects could include psychotic sx, seizures, cardiovascular events and
arrhythmia. There is an increased risk of arrhythmia or cardiovascular problems in persons with a personal history of cardiac disease or stroke or a family history of cardiac or stroke at an early age or sudden death. There is a risk of worsening or side effects of glaucoma, vision changes or eye pain. Stimulants have a risk of dependency and addiction.People can develop tolerance necessitating increases in doses. if possible, it is helpful to take the medication only on days in which it is needed Informed Consent:
Psychoeducation provided as to the benefits, risks, side effects, and alternatives to the patient’s medication treatment plan.

Provider and patient discussed the danger of misuse of stimulant medications and the patient agreed to take medication only for themselves. The patient is to contact our office with any questions, concerns, adverse side effects, or changes in mental health status. The patient is advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans. The patient is advised against using alcohol and/or illicit substances while on psychotropic medication due to the risk of negative interactions and is aware doing so will be at his/her own risk. It is recommended that the patient should discuss this diagnosis and treatment plan with their PCP as well, as we don't want to have overriding and/or conflicting plans. The patient is encouraged to follow up with PCP for routine health and lab monitoring and maintenance.The patient verbalizes understanding, agrees to this treatment plan,and agrees to coordinate care as needed.


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