Inital Evaluation

Date:[date name="variable_1" default="03-20-2023"]
Time:[text name="variable_2" default=""]

*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*

[text name="variable_3" default=""]  is a AGE  [text name="variable_4" default=""][select name="variable_5" value="female|male|nonbinary|she|they|he|him|them"] who presents for an initial psychiatric evaluation with chief concerns of ADHD. 

HISTORY OF PRESENT ILLNESS:
Age of symptom onset[text name="variable_6" default=""]
History of impairment and any former treatment[textarea name="variable_7" default=""]
Current symptoms and current functional impairments across settings[select name="variable_8" value="Home|Work|School|Church|Social Settings"]

PSYCHIATRIC REVIEW OF SYSTEMS:
ADHD: 
ASRS- A Evaluation Score: [text name="variable_9" default="sample text"]
Patient ENDORSES [textarea name="variable_10" default=""] # out of 9 inattentive symptoms of ADHD as occurring often or very often, including[checklist name="variable_11" value="problems following through on directions|unfinished tasks|difficulty with organization|is 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 ENDORSES[textarea name="variable_12" default=""] # out of 9 hyperactivity symptoms of ADHD as occurring often or very often, including [checkbox name="variable_13" 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:[text name="variable_14" default=""]
Patient [select name="variable_15" value="DENIES|ENDORSES"] symptoms of DEPRESSION including
[checkbox name="variable_16" value="loss of interest in pleasurable activities|sad mood and feelings of hopelessness|sleep alteration|problems with energy|appetite disturbance|feelings of guilt or worthlessness|problems with concentration|psychomotor disturbance|passive suicidal thoughts"]

ANXIETY: 
GAD-7 Score:
Patient [select name="variable_17" value="DENIES|ENDORSES"]symptoms of GENERALIZED ANXIETY, including[checklist name="variable_18" value="excessive worrying throughout the day associated with,|feeling nervous and on edge|constant worry|racing thoughts|trouble relaxing|feeling restless|Irritability|feelings of impending doom"]
Triggers: [textarea name="variable_19" default=""]

PANIC: 
Patient [select name="variable_20" value="ENDORSES|DENIES"]symptoms of PANIC ATTACKS
Triggers:[textarea name="variable_21" default=""]
Frequency:[checklist name="variable_22" value="Daily|Weekly|Monthly"]

INSOMNIA:
Sleep routine:[textarea name="variable_23" default=""]
Average hours of sleep per night:[checklist name="variable_24" value="2 hrs|3hrs|4hrs|5hrs|6hrs|7hrs|8hrs|9hrs|10hrs|11hrs|12 or more hours"]
Patient [select name="variable_25" value="ENDORSES|DENIES"] symptoms of INSOMNIA, including:[checklist name="variable_26" value="difficulty falling asleep|difficulty staying asleep"]

MANIA/HYPOMANIA:
Patient [select name="variable_27" value="ENDORSES|DENIES"] symptoms of MANIA/ HYPOMANIA including:[checklist name="variable_28" value="distinct periods of abnormal or elevated,| expansive, or irritable mood| marked increase in energy|reckless/ impulsive behaviors such as increased money spending or hypersexuality|decreased need for sleep|racing thoughts|increased/ pressured speech"]

OTHER:
Patient also [select name="variable_29" value="Endorses|Denies"] any history of, or current concerns relating to:[checklist name="variable_30" value="Trauma or Abuse|Intrusive thoughts|Paranoid or delusional thoughts|Psychosis|Auditory hallucinations|Visual hallucinations|Cognitive alterations|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="variable_31" value="endorses|denies"]
Current suicidal thoughts/ ideation: [select name="variable_32" value="endorses|denies"]
Suicidal intention/ plan:[checklist name="variable_33" value="endorses|denies"][textarea name="variable_34" default=""]
Access:[checklist name="variable_35" value="firearms|denies"] [textarea name="variable_36" default=""]
Self-injurious behaviors (ie, cutting): [checklist name="variable_37" value="cutting|picking skin|self mutilation|pulling hair|denies"]
Hx of violence / homicidal ideations with plan or intent: [text name="variable_38" default=""]

Previous Psychiatric medication trials:  [text name="variable_39" default=""]
Past Psychiatric Hospitalizations: [text name="variable_40" default=""]
Past or Current Therapy/ Counseling:[text name="variable_41" default=""]

MEDICAL HISTORY:
Current Height:[text name="variable_42" default=""]
Current Weight:[text name="variable_43" default=""]
PCP name:[text name="variable_44" default=""]    
Last PCP appointment: [text name="variable_45" default=""]
ROS:
Medical conditions reported by the patient: [text name="variable_46" default=""]
the patient denies a history of any [checklist name="variable_47" value="heart arrhythmias| hypertension|stroke|seizures|other neurological|cardiac disorders"]. 
Drug Allergies: [text name="variable_48" default=""]
Current Daily Medications: [text name="variable_49" default=""]

Female patients:
[checkbox name="variable_50" value="currently pregnant|family planning|currently breastfeeding|using birth control"] 

FAMILY HISTORY:
Pertinent Family History of Mental Health Conditions:[text name="variable_51" default=""]
Pertinent Family History of Medical Conditions: [text name="variable_52" default=""]
patient denies a [checklist name="variable_53" value="family history of any heart conditions including but not limited to|sudden cardiac arrest|irregular heartbeats|heart attack before the age of 55|They report no other family medical history"].

SOCIAL/ LIFESTYLE :
Housing: [checklist name="variable_54" value="Lives with spouse|Lives with significant other|lives with parents|lives with grandparents|lives with roomate"]
The patient reports their housing is [select name="variable_55" value="stable|unstable"] and currently feels [select name="variable_56" value="safe|unsafe"] in their home environment.

Relationships/ Support: [checklist name="variable_57" value="spouse|significant other|parents|children|aunt|uncle|brother|sister|grandmother|grandfather|friend"]
Partner: [select name="variable_58" value="married|unmarried|single|divorce|widow"]    
Children:[checklist name="variable_59" value="0|1|2|3|4|5|6|7|8|9|10"]
Family/ Friends:

Career/School: [text name="variable_60" default=""]
Occupation/ Major: [text name="variable_61" default=""]                       
Work/ School hours:[text name="variable_62" default=""]
Military: [select name="variable_63" value="currently serving|previously served|denies any service"]

Legal or Financial Issues:[select name="variable_64" value="endorses|denies"]
Physical Activity/ Hobbies:[text name="variable_65" default=""]
Diet/ Nutrition/ Appetite Issues:[text name="variable_66" default=""]
Any New or Worsening Stressors:[text name="variable_67" default=""]

SUBSTANCE USE:[select name="variable_68" value="endorses|denies"]
Caffeine:[text name="variable_69" default=""] 
Alcohol: [text name="variable_70" default=""]
Nicotine products: [checklist name="variable_71" value="cigarettes|cigars|vapes|denies"]
Marijuana: [checklist name="variable_72" value="smokes|ingests|denies"]
Any other substances including, but not limited to: [checklist name="variable_73" value="sedatives|opioids|hallucinogens|club drugs| cocaine|denies"]
Currently undergoing rehabilitation:[checklist name="variable_74" value="alcohol|opioid|sexual|denies"]
*Pt [select name="variable_75" value="Not counseled|counseled"]on the importance of being substance-free*

MENTAL STATUS EXAM:
Appearance: [checklist name="variable_76" value="well-developed|well-nourished|appropriate grooming|appears stated age|good eye contact|in no acute distress"]
Orientation: [checklist name="variable_77" value="alert|oriented to person|place|time"]
Speech:[checklist name="variable_78" value="spontaneous|pressured|normal rate"] 
Mood: [checklist name="variable_79" value="good|happy|elated|angry|hostile"]
Affect: [checklist name="variable_80" value="appropriate|mood-congruent"]
Behavior: [select name="variable_81" value="calm|shy|appropriate|inappropriate"]
Thought Process:[checklist name="variable_82" value=" linear|goal-directed|associations tight|loose associations|tangential"]
Thought Content: [checklist name="variable_83" value="pt denies Suicidal ideation|Homicidal Ideation|Auditory Hallucination|Visual Hallucinations|Delusions "]  
Cognition: [checklist name="variable_84" value="memory intact|attention intact|concentration intact|in the normal range"]
Judgment: [checklist name="variable_85" value="good|unimpaired|poor|imparied"]
Insight: [checklist name="variable_86" value="good|poor"]
            

ASSESSMENT:
Patient[text name="variable_87" default=""] is an AGE[text name="variable_88" default=""]  yo [select name="variable_89" value="female|male|nonbinary|she|they|he|him|them"]

with past psychiatric history of [text name="variable_90" default=""][checklist name="variable_91" value="presenting with concerns for ADHD|presenting with concerns for ADHD|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[checkbox name="variable_92" value="Inattentive ADHD F90.0|Hyperactive ADHD F90.1|Combined F90.2"][checklist name="variable_93" value="Depression|Obsessive Compulsive Disorder|Schizophrenia|Anxiety|Insomnia|Acute Adjustment Disorder|PTSD|Bipolar|Bipolar with mixed symptoms|Bipolar with psychotic features"]

The patient reports their symptoms are causing maladaptive functioning and impairment across their[checklist name="variable_94" value="interpersonal|occupational|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 pharmacological management with[text name="variable_95" default=""]
The patient currently [select name="variable_96" value="endorses|denies"] [checklist name="variable_97" value="suicidal or homicidal ideation"].

DIAGNOSES:
[select name="variable_98" value="F90.0 Predominantly inattentive ADHD|Predominantly hyperactive|F90.2 Combined ADHD"]
PLAN:[text name="variable_99" default=""]
Treatment goals:[checklist name="variable_100" value="reduction of inattentive ADHD|reduction of hyperactive ADHD| reduction of combined ADHD"]
[text name=Pharmacy name:               "]
Pharmacological Interventions:[text name="variable_101" default=""]
[select name="variable_102" value=start:continue|discontinue]
[text name="variable_103" default=""]
Non-Pharmacological Interventions:
[checklist name="variable_104" value="Cognitive Behavioral Therapy|Exercise|Dietary modifications|Dialetical Behavioral Therapy"]


RECOMMENDED FOLLOW-UP: 
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 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. 

LaCresha Earley PMHNP BC, FNP-C, APRN