Psychiatry
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Identifying Information:
[text name="name" 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"][text memo="other gender" value="20"] who [select value="lives with their significant other |lives with their family |lives alone |is homeless|lives with their parents |lives with their children |lives with a roommate |lives in a grouphome |"][text size="20"] 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:
[var name="name"] [select value="presents in this initial outpatient appointment| "][select value=" alone| with family| with significant other| with DHHS worker| with case manager|"][text memo="names" size="20"][select value=" for evaluation and management of the chief complaint of | due to reports of |"][text memo="presenting problem" size="20"].[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('')"]

[var name="name"]'s depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|self harm|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 for the past |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('')"]

[var name="name"]'s anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|panic|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor concentration|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=" 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|tactile hallucinations|olfactory hallucinations|homicidal ideation| 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 field="adhd" condition="(adhd).is('')"]

[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" 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"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" 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"].[/conditional][conditional field="adhd" condition="(adhd).is('')"] These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3"][/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]

[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."]

When asked about any traumatic symptoms the patient[select name="variable_312341" value=" denied having trauma.| stated traumatic symptoms which included|"] [checkbox name="variable_43653241" value="Recurrent, unwanted distressing memories of the traumatic event|flashbacks|upsetting dreams/nightmares|severe emotional distress that reminds pt of trauma|physical reactions to something that reminds the pt of the traumatic event|Trying to avoid thinking or talking about the traumatic event|Avoiding places, activities or people that remind you of the traumatic event|negative thoughts about self|negative thoughts about other people|hopelessness about the future|memory disturbances r/t to not remembering important aspects of the trauma|difficulty maintaing close relationships|feeling detached from family and friends|lack of interest in activites they used to enjoy doing|difficulty experiencing positive emotions|feeling emotionally numb|easily startled|always being on guard for danger|self destructive behavior|difficulty sleeping|aggressive behavior|trouble concentrating|angry outbursts|trouble concentrating|overwhelming guilt|trouble concentrating|overwhelming shame"]

[checkbox memo= "Scales" name="scales" value=""][conditional field="scales" condition="(scales).is('')"]
Scales and Screening:
PHQ-9: [select value="unable to assess|N/A|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|N/A|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|N/A|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|N/A|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|N/A|unable to assess|declined|1|2|3|4"]
AUDIT:[select value="negative|unable to assess|N/A|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|N/A|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"][/conditional]


PAST PSYCHIATRIC HISTORY:
[select name="variable_1" value="The patient states a past diagnosis of|The patient denies a past psychiatric diagnosis"][textarea name="variable_1" default="sample text"][select value="There is no history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="2"]. [select value="When asked about psychotherapy the patient stated | no history of psychotherapy|history of psychotherapy/counseling|"][textarea rows="2"]. [select value="They deny history of diagnosis/treatment for an eating disorder|They report positive for a history of diagnosis/treatment for an eating disorder including |Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation|History of diagnosis/treatment of an eating disorder was not assessed in this encounter|"][textarea rows="1"].[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 hallucinations| They have a history hallucinations|Unable to obtain history of hallucinations due to symptomatic presentation"][textarea rows="2"] [select value="They have no history of delusions| They have a history delusions|Unable to obtain history of hallucinations due to symptomatic presentation"][textarea rows="2"][select value="They have no history of attempting suicide|They have a history of attempting suicide |Unable to obtain history of suicide attempt due to symptomatic presentation"][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="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"].


MEDICAL HISTORY:
Other Providers: [text name="variable_4111631" default="sample text"]
Illness: [text name="variable_4631" default="sample text"]
Surgeries: [text name="variable_43631" default="sample text"]
Allergies: [text name="variable_463451" default="sample text"]
Head Injuries: [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"].
Seizures: [select value="They denied having seizures|They have a past history of seizures|"][textarea rows="2"].
[select value="Current psychiatric medications include: |They are not currently taking any psychiatric medications|Patient is unable to recall current medications|Unable to cover current psychiatric medications with patient due to symptomatic presentation|"][textarea rows="4"].[select name="medmed" value=" Other medical medications include: | Other medical medications are noted below."][conditional field="medmed" condition="(medmed).isNot(' Other medical medications are noted below.')"][textarea rows="3"].[/conditional][select value=" Medication list obtained from patient.| Medication list obtained from medical record.| Medication list obtained from patient's guardian. | Medication list confirmed with patient's pharmacy.| Medication list confirmed with patient's grouphome.| "]


SOCIAL HISTORY:
[var name="name"] identifies [checkbox value="having no one |significant other |extended family |children |friends |church members "][textarea rows="1"] as their social-support network. The patient has [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children. The patients level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |a doctorate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"]. The patient is[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 the patient has[select value=" no immediate concerns| been burdened by healthcare costs| concerns related to supporting their family|"][textarea rows="1"].The patient source of income is primarily [select value=" disability| social security| unemployment| child support| current employment| family support| retirement|"][textarea rows="1"].The patient has [select value=" no current housing concerns| a currently unstable housing situation related to |"][textarea rows="1"]. [select name="spirituality" value="Spirituality was not addressed this visit|Spirituality is identified as |"][conditional field="spirituality" condition="(spirituality).is('Spirituality is identified as ')"][select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Satanism|Agnostic|Spiritual but no specific religion|Hinduism|"][textarea rows="1"][/conditional]. [select value="Cultural considerations important to care include: |"][textarea rows="1"].Sexual orientation [select name="sexuality" value="is identified as |was not addressed this visit|"][conditional field="sexuality" condition="(sexuality).is('is identified as ')"][select value="heterosexual|homosexual|bisexual|pansexual|asexual|"][textarea rows="1"][/conditional].[select value="No past history of military service|Military history includes |Military history was not addressed this visit|"][textarea rows="1"]. [select value="At this current time the patient has no current legal concerns|At this time the patient has legal concerns which include |legal concerns at this time were not addressed due to symptomatic presentation"][textarea rows="1"].
[select value="The patient reports positive for tobacco use consuming approximately |The patient reports a past history of tobacco but quit approximately |The patient denies any tobacco use|"][textarea rows="1"].[select value="The patient reports positive for alcohol use consuming approximately |The patient reports a history of alcohol abuse quitting approximately |The patient denies any alcohol use|"][textarea rows="2"]. [select value="They deny a history of recreational substance use|The patient reports utilizing cannabis approximately |The patient has a history of substance abuse in the form of |They report utilizing opiates recreationally in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="4"].

DEVELOPMENTAL HISTORY:
[select value="There is no known issue with meeting expected developmental milestones|All developmental milestones were met with exception to |There were some notable issues with developmental milestones including |"][textarea name="variable_1" default="sample text"]. Their primary language includes [select name="language" value="English|"][conditional field="language" condition="(language).is('')"][text memo="language" size="15"][/conditional] and utilizes [select name="comskill" value="written and verbal communication|primarily verbal communication|primarily textual communication and sign language| "][textarea rows="1"].


FAMILY HISTORY:
[var name="name"] was born in [text memo="place of birth" size="20"] [select value="to an intact family |to a family structure consisting of |"][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"].
Identifying Information:
Patient name is a age-year-old, ethnicity, other gender who in residing location. guardian.Additional presentation information

History of Presenting Illness:
name namespresenting problem. depression anxiety sleep mood ptsd adhd autism

. . .

When asked about any traumatic symptoms the patient

Scales


PAST PSYCHIATRIC HISTORY:
. . .. . . . .


MEDICAL HISTORY:
Other Providers:
Illness:
Surgeries:
Allergies:
Head Injuries: .
Seizures: .
.


SOCIAL HISTORY:
name identifies as their social-support network. The patient has children. The patients level of education is . The patient is.Financially the patient has.The patient source of income is primarily .The patient has . . .Sexual orientation .. .
.. .

DEVELOPMENTAL HISTORY:
. Their primary language includes and utilizes .


FAMILY HISTORY:
name was born in place of birth .

...

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