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*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
Identifying Information:
[text memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"], [checkbox value="single|married|partnered"] [checkbox value="female|male|transgender female|transgender male|gender non-binary individual"] who [checkbox value="lives alone|is homeless|lives with significant other|lives with parents|lives with a roommate|lives in a grouphome"] in [text memo="residing location" size="20"]. [select value="They are their own guardian|They have a DHS guardian |Their guardian is |"][text memo="guardian" size="20"]. [textarea memo="Additional presentation information" rows="5"]

History of Presenting Illness:
The patient [select value="presents in this outpatient appointment |initially presented to the emergency department "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police"][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |"][text memo="presenting problem" size="20"]. [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past history of |no history of mental health concerns until |no history of mental health concerns|"][textarea memo="Mental health history" rows="5"]. [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"] The patient's depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].[textarea memo="Additional Depression information" rows="5"][/conditional][conditional field="anxiety" condition="(anxiety).is('')"] The patient's anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"][select value=" The patient's 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="sleep" condition="(sleep).is('')"]Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional][conditional field="sleep" condition="(sleep).isNot('')"]Sleep is reported to be generally good. [/conditional][conditional field="depression" condition="(depression).isNot('')"]They deny any marked issues with depression. [/conditional][conditional field="anxiety" condition="(anxiety).isNot('')"]They deny any significant issues with anxiety. [/conditional][conditional field="mood" condition="(mood).isNot('')"]They deny a history of mania, excessive mood lability, grandiosity, or uncharacteristic risk taking behavior. [/conditional]

[select value="Current psychiatric medications include: |Patient is unable to recall current psychiatric medications|Unable to cover current psychiatric medications with patient due to symptomatic presentation|"][textarea rows="4"]. [select value="They are not currently receiving individual counseling/therapy|They are currently engaging in individual counseling with |"][textarea rows="1"]. [select value="They deny current suicidal ideation or thoughts of self harm|They report positive for |They deny suicidal ideation but state having thoughts of being better off dead"][textarea rows="1"]. [checkbox value="They are able to contract for safety.|They deny being able to contract for safety."][textarea rows="1"] [select value="They deny having access to guns|They report positive for having guns in the home |"][textarea rows="1"]. [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]

Scales and Screening:
PHQ-9: [select value="unable to assess|declined|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|28|29|30"]
GAD-7: [select value="unable to assess|declined|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|28|29|30"]
MDQ: [select value="negative|unable to assess|declined|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|28|29|30"]
HITS:[select value="negative|unable to assess|declined|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|28|29|30"]
PC-PTSD:[select value="negative|unable to assess|declined|1|2|3|4"]
AUDIT:[select value="negative|unable to assess|declined|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|28|29|30"]
DAST-10:[select value="negative|unable to assess|declined|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|28|29|30"]
SLUMS:[select value="N/A|unable to assess|declined|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|28|29|30"]

[select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|We were unable to cover previous psychiatric medication trials due to symptomatic presentation|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"]. [select value="There is no history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="2"]. [select value="Previous psychiatric/counseling services includes |They have no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"]. [select value="They have no history of thoughts of self-harm|History of thoughts of self harm include |"][textarea rows="2"]. [select value="They have no history of attempting to hurt themself|History of self-harm includes |Unable to obtain history of self-harm due to symptomatic presentation"][textarea rows="2"]. [select value="They have no history of head injuries or traumatic brain injuries|They have a past history of traumatic brain injuries resulting from |They have an underlying cognitive impairment from |"][textarea rows="2"]. [select value="There is no history of trauma|They report having a history of trauma but did not want to elaborate|They report past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="2"]. [select value="They report positive for tobacco use consuming approximately |They report a past history of tobacco but quit approximately |They deny any tobacco use|"][textarea rows="1"]. [select value="They report positive for alcohol use consuming approximately |They report a history abuse quitting approximately |They deny any alcohol use|"][textarea rows="2"]. [select value="They deny a history of recreational substance use|They report utilizing cannabis approximately |They have a history of opiate use disorder |They report utilizing opiates recreationally in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="4"].

Patient identifies [checkbox value="having no one as|significant other|extended family|children|friends|church members"][textarea rows="1"] social-support network. They have [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children. They are [select value="currently on disability due to their mental health condition|currently on disability due to their medical condition|currently employed |currently retired from |"][textarea rows="1"]. Financially they [select value="have no immediate concerns|are burdened by healthcare costs|have concerns related to supporting their family|"][textarea rows="1"]. Their source of income is primarily [select value="disability|social security|unemployment|current employment|family support|"][textarea rows="1"]. They have [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="1"]. [select value="Spirituality was not addressed this visit|Spirituality is identified as |"][select value="|Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"]. Sexual orientation [select value="was not addressed this visit|is identified as |"][select value="|heterosexual|homosexual|bisexual|pansexual|asexual"][textarea rows="1"]. [select value="They have no military history|Military history includes |Military history was not addressed this visit|"][textarea rows="1"]. [select value="They have no current legal concerns|Legal concerns include |Legal concerns were not addressed due to symptomatic presentation"][textarea rows="1"].

[select value="They deny knowledge of a family history of mental illness|Family history of mental health problems is positive for |Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="4"]. [select value="There is no known history of suicides or self-harm in the patient's family|Family history of suicides/self-harm includes |Unable to cover family history of suicides/self-harm due to symptomatic presentation|"][textarea rows="2"]. [select value="There is no known family history of substance use issues|Family history of substance use is positive for |Unable to cover family history of substance use issues due to symptomatic presentation|"][textarea rows="4"].
*Chief Complaint*
Date and Time of Service:
Identifying Information:
Patient name is a age-year-old, ethnicity, who in residing location. guardian. Additional presentation information

History of Presenting Illness:
The patient namespresenting problem. Mental health history. depression anxiety sleep mood ptsd adhd autism

. . . .

Scales and Screening:

. . . . . . . . . .

Patient identifies social-support network. They have children. They are . Financially they . Their source of income is primarily . They have . . Sexual orientation . . .

. . .
Result - Copy and paste this output: