dsm

MOOD DISORDERS

[checkbox name="bene4" memo="Major Depressive Disorder" value=""][conditional field="bene4" condition="(bene4).is('')"]Major Depressive Disorder: [comment memo="diagnosis requires 5 symptoms for mild; 6-7 for moderate; 8-9 for severe"] [checkbox value="depressed mood|diminished interest/pleasure in all or almost all activities|significant change in weight|insomnia or hypersomnia|psychomotor agitation/retardation|fatigue or loss of energy|feeling worthless or excessive/inappropriate guilt|decreased concentration|thoughts of death/suicide" rows="1"]. 
Symptoms are present most of the day, nearly every day and cause significant distress or impairment in functioning. Episode is not attributable to substant use or another medical consition and is not better explained by another mental health condition. There is no history of mania/hypomania. PQH9 SCORE [text name="variable_52" default=""] as of [date name="variable_1" default="12-09-2022"].
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[checkbox name="bene4" memo=[select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]

[select value="Per patient,|Per family,|Per record,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional 

ANXIETY DISORDERS

[checkbox name="bene2" memo="Generalized Anxiety Disorder" value=""][conditional field="bene2" condition="(bene2).is('')"]Generalized Anxiety Disorder: Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities. Difficulty controlling worry. The anxiety and worry are associated with:[comment memo="diagnosis requires at least 3 of the following"] [checkbox value="restlessness, feeling keyed up or on edge|being easily fatigued|difficulty concentrating|irritability|muscle tension|sleep disturbance" rows="1"]. Symptoms cause clinically significant distress or impairment in functioning. Symptoms are not attributable to substance use or another medical condition and are not better explained by another mental health condition. GAD7 SCORE [text name="variable_52" default=""] as of [date name="variable_1" default="12-09-2022"].
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[checkbox name="bene11" memo="Social Anxiety Disorder" value=""][conditional field="bene11" condition="(bene11).is('')"]
Marked fear or anxiety about one or more social situations and being exposed to possible scrutiny by others. Social situations almost always provoke fear or anxiety that is out of proportion and cause avoidance of social situations. Social situations are endured with intense fear and anxiety. Symptoms cause significant distress or impairment in functioning, have been present for at least 6 months and are not attributable to effects of a substance or another medical condition. GAD7 SCORE [text name="variable_52" default=""] as of [date name="variable_1" default="12-09-2022"].[/conditional]

[checkbox name="bene7" memo="Panic Disorder" value=""][conditional field="bene7" condition="(bene7).is('')"]Panic Disorder: Panic attacks described as an abrupt surge of intense fear or discomfort with symptoms of [comment memo="four or more of the following"][checkbox value="palpitations|sweating|trembling/shaking|sensations of SOB or smothering|feeling of choking|chest pain|nausea/abdominal distress|feeling dizzy, lighteaded or faint|derealization or depersonalization|fear of losing control or going crazy|fear of dying|paresthesias|chills or hot flushes" rows="1"] that reach a peak within minutes. Panic attacks are recurrent and unexpected and at least one attack is followed by persistent concern about additional attacks and a significant maladaptive change in behavior. The panic attacks are not due to the effects of a substance or another medical or mental disorder.
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[checkbox name="bene0" memo="Post Traumatic Stress Disorder" value=""][conditional field="bene0" condition="(bene0).is('')"]Post Traumatic Stress Disorder: Exposure to traumatic event by [checkbox value="direct experience|witnessing, in person the event(s) as it occured to others|learning that traumatic event occured to close family or friend|experiencing repeated or extreme exposure to aversive details of the traumatic event" rows="1"]. Presence of [comment memo="one or more of the following"][checkbox value="recurrent, involuntary and intrusive distressing memories|recurrent distressing dreams relating to traumatic event|dissociative reactions or flashbacks|intense or prolonged psychological distress with exposure to reminders of trauma|marked physiological reactions to reminders of traumatic events" rows="1"] which began after the tramatic event occured. Persistent avoidance of stimuli associated with the traumatic event(s) as evidenced by one or both of the following:[checkbox value="avoidance of or efforts to avoid distressing memories, thoughts or feelings about the trauma|avoidance of or efforts to avoid external reminders that trigger thoughts of trauma" rows="1"]Negative alterations in cognitions and mood associated with the traumatic event(s) as evidenced by 
[comment memo="2 or more of the following"][checkbox value="dissociative amnesia|persistent and exaggerated negative beliefs or expectations about self, others or the world|distorted cognitions about the cause or consequences of the traumatic event|negative emotional state|diminished interest in significant activities|feelings of detachment from others|inability to experience positive emotions" rows="1"]. Marked alterations in arousal and reactivity as evidenced by[comment memo="2 or more of the following"][checkbox value="irritable behavior/anger outbursts|reckless or self-destructive behavior|hypervigilance|exaggerated startle response|problems with concentration|sleep disturbance" rows="1"]. Symptoms present for more than 1 month and cause clinically significant distress or impairment in functioning. Symptoms are not attributable to substance use or another medical condition.
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[checkbox name="bene" memo="Attention Deficit Disorder" value=""][conditional field="bene" condition="(bene).is('')"]Attention Deficit Disorder:[comment memo="F90.0 requires 6 inattentive symptoms"] [checkbox value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities" rows="1"] [comment memo="F90.1 requires 6 hyperactive/impulsive symptoms F90.2 requires 6 of each"][checkbox value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others" rows="1"]. Symptoms began before age 12. Symptoms cause significant impairment in multiple settings and are not better explained by another mental health disorder. ADHD Adult Scale Part A)[select name="variable_2" value="1|2|3|4|5|6"] out of 6, Part B)[select name="variable_3" value="1|2|3|4|5|6|7|8|9|10|11|12"] out of 12 on [date name="variable_4" default="12-02-2022"].
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[checkbox name="bene01" memo="Insomnia" value=""][conditional field="bene01" condition="(bene01).is('')"]Insomnia: dissatisfaction with [select name="variable_01" value="quality|quantity|quality and quantity"] of sleep, associated with[comment memo="one or more of the following"] [checkbox value="difficulty initiating sleep|difficulty maintaining sleep|early morning awakening + inability to return to sleep" rows="1"]. The sleep difficulty occurs [select name="variable_02" value="3|4|5|6|7"] nights per week, have been present for [text name="variable_03" default="at least 3 months"] and occurs despite adequate opportunity for sleep. Insomnia causes clinically significant [select name="variable_04" value="distress|impairment in social functioning|impairment in occupational functioning|impairment in academic functioning"] and is not attributable to the physiological effects of a substance. The sleep disorder is not better explained by another sleep-wake disorder and coexisting mental health disorders/medical conditions do not adequately explain the complaint of insomnia.[/conditional]

[checkbox name="bpd" memo="Borderline Personality Disorder" value=""][conditional field="bpd" condition="(bpd).is('')"]Borderline Personality Disorder: A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by [comment memo="diagnosis requires at least 5 symptoms"] [checkbox value="frantic efforts to avoid real or imagined abandonment|a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation|identity disturbance: markedly and persistently unstable self-image or sense of self|impulsivity in at least 2 areas that are potentially self-damaging|recurrent suicidal behaviour, gestures or threats, or self-mutilating behavior|affective instability due to a marked reactivity of mood|chronic feelings of emptiness|inappropriate, intense anger or difficulty controlling anger|transient, stress-related paranoid ideation or severe dissociative symptoms" rows="1"].
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SUBSTANCE USE DISORDERS

[checkbox name="beneb" memo="Alcohol Use Disorder" value=""][conditional field="beneb" condition="(beneb).is('')"]Alcohol Use Disorder, [select name="variable_00" value="Mild|Moderate|Severe"] [comment memo="Mild; 2-3 symptoms Moderate 4-6 symptoms Severe 6+ symptoms"]A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by: [checkbox value="alcohol is taken in larger amounts or over longer period than was intended|persistent desire or unsuccessful attempts to cut down or control alcohol use|a great deal of time is spent obtaining, using or recovering from effects, cravings|failure to fulfill major obligations at work, school or home|continued use despite recurrent social or interpersonal problems due to alcohol use|important activities are given up because of alcohol use|alcohol use in potentially physically hazardous situations|continued alcohl use despite having a physical or psychological problem that is caused or exacerbated by alcohol use" rows="1"]. Positive Cage Screening with a score of [select name="variable_gh" value="2|3|4"]/4 as of [date name="variable_jh" default="12-10-2022"].[/conditional]

[checkbox name="cann" memo="Cannabis Use Disorder" value=""][conditional field="cann" condition="(cann).is('')"][comment memo="Mild; 2-3 symptoms Moderate 4-6 symptoms Severe 6+ symptoms"]
Cannabis Use Disorder, [select name="variable_cann" value="Mild|Moderate|Severe"]: A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by [checkbox value="cannabis taken in larger amounts or over longer period than was intended|persistent desire or unsuccessful attempts to cut down or control cannabis use|a great deal of time spent obtaining, using or recovering from effects|cravings to use cannabis|failure to fulfill major obligations at work, school or home due to use|continued use despite recurrent social or interpersonal problems due to cannabis use|important activities given up because of cannabis use|cannabis use in potentially physically hazardous situations|continued cannabis use despite having a physical or psychological problem that is caused or exacerbated by use" rows="1"]. DAST-10 Score of [text name="variable_cann" default=""] as of [date name="variable_cann" default="12-10-2022"] which suggests [select name="variable_cann1" value="no problems related to drug abuse|low level of problems realted to drug abuse|moderate problems realted to drug abuse|substantial problems realted to drug abuse|severe problems realted to drug abuse"].[/conditional]

[checkbox name="opi" memo="Opioid Use Disorder" value=""][conditional field="opi" condition="(opi).is('')"][comment memo="Mild; 2-3 symptoms Moderate 4-6 symptoms Severe 6+ symptoms"]
Opioid Use Disorder, [select name="variable_opi" value="Mild|Moderate|Severe"]: A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by [checkbox value="opioids taken in larger amounts or over longer period than was intended|persistent desire or unsuccessful attempts to cut down or control opioid use|a great deal of time spent obtaining, using or recovering from effects|cravings to use opioid|failure to fulfill major obligations at work, school or home due to use|continued use despite recurrent social or interpersonal problems due to opioid use|important activities given up because of opioid use|opioid use in potentially physically hazardous situations|continued opioid use despite having a physical or psychological problem that is caused or exacerbated by use" rows="1"]. [comment memo="1-2: low level|3-5: moderate|6-8: substantial|9-10: severe"] 
DAST-10 Score of [text name="variable_opi" default=""] as of [date name="variable_opi" default="12-10-2022"] which suggests [select name="variable_opi1" value="no problems related to drug abuse|low level of problems realted to drug abuse|moderate problems realted to drug abuse|substantial problems realted to drug abuse|severe problems realted to drug abuse"].[/conditional]

[checkbox name="coc" memo="Cocaine Use Disorder" value=""][conditional field="coc" condition="(coc).is('')"][comment memo="Mild; 2-3 symptoms Moderate 4-6 symptoms Severe 6+ symptoms"]
Cocaine Use Disorder, [select name="variable_coc" value="Mild|Moderate|Severe"]: A problematic pattern of cocaine use leading to clinically significant impairment or distress, as manifested by [checkbox value="cocaine taken in larger amounts or over longer period than was intended|persistent desire or unsuccessful attempts to cut down or control cocaine use|a great deal of time spent obtaining, using or recovering from effects|cravings to use cocaine|failure to fulfill major obligations at work, school or home due to use|continued use despite recurrent social or interpersonal problems due to cocaine use|important activities given up because of cocaine use|cocaine use in potentially physically hazardous situations|continued cocaine use despite having a physical or psychological problem that is caused or exacerbated by use" rows="1"]. [comment memo="1-2: low level|3-5: moderate|6-8: substantial|9-10: severe"] 
DAST-10 Score of [text name="variable_coc" default=""] as of [date name="variable_coc" default="12-10-2022"] which suggests [select name="variable_coc1" value="no problems related to drug abuse|low level of problems realted to drug abuse|moderate problems realted to drug abuse|substantial problems realted to drug abuse|severe problems realted to drug abuse"].[/conditional]



[checkbox name="meth" memo="Methamphetamine Use Disorder" value=""][conditional field="meth" condition="(meth).is('')"][comment memo="Mild; 2-3 symptoms Moderate 4-6 symptoms Severe 6+ symptoms"]
Methamphetamine Use Disorder, [select name="variable_meth" value="Mild|Moderate|Severe"]: A problematic pattern of methamphetamine use leading to clinically significant impairment or distress, as manifested by [checkbox value="Methamphetamine taken in larger amounts or over longer period than was intended|persistent desire or unsuccessful attempts to cut down or control Methamphetamine use|a great deal of time spent obtaining, using or recovering from effects|cravings to use Methamphetamine|failure to fulfill major obligations at work, school or home due to use|continued use despite recurrent social or interpersonal problems due to Methamphetamine use|important activities given up because of Methamphetamine use|Methamphetamine use in potentially physically hazardous situations|continued Methamphetamine use despite having a physical or psychological problem that is caused or exacerbated by use" rows="1"]. [comment memo="1-2: low level|3-5: moderate|6-8: substantial|9-10: severe"] 
DAST-10 Score of [text name="variable_meth" default=""] as of [date name="variable_meth" default="12-10-2022"] which suggests [select name="variable_meth1" value="no problems related to drug abuse|low level of problems realted to drug abuse|moderate problems realted to drug abuse|substantial problems realted to drug abuse|severe problems realted to drug abuse"].[/conditional]