intake

CHIEF COMPLAINT: [text default=" This is an initial medical assessment on __________ who has been admitted for residential services for withdrawal management and recovery of:" size=100][checkbox name="sud" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"]

HISTORY OF PRESENT ILLNESS:
Patient is a [text default="" size=2]-year-old [select name="RACE" value="Caucasian|African American|Asian"], [select name="GENDER" value="male|female"], with PMH of [text default="" size=100]. Patients BAC was
[text name="variable_1" default="***"]on admission. The patient was admitted [date name="DATE" default=""].

[comment memo="Story of what happened:"][textarea fillable="true"]Patient was in ****** normal state of health until ******.[/textarea]

SUBSTANCE ABUSE HISTORY:
•[comment memo="When did they start, how often, last used"][textarea name="2" default=""]
•[select value="Patient does not recall substance abuse treatment history or detox attempts| Patient reflects substance abuse treatment history or detox attempts as: "]
[comment memo="Any inpatient/outpatient addiction treatment program"][textarea name="txhx" default=""]
•Patient reflects that substance use has:
[checkbox name="affect" value="affected ADLS|affected relationships|affected finances"]
• Patient's history of sobriety has been: [comment memo="How long, sobriety, rehab"][textarea name="sober" default=""]
•[select value="Patient does not have a history of seizure or DTs| Patient has a history of seizure or DTs |"]
[comment memo="Alcohol withdrawal (DT/seizures), when was last drink"]
[textarea name="lastusehx" default=""]


PSYCHIATRIC HISTORY:
[comment memo="DEPRESSION: (Sleep problems, interest, guilt, energy, concentration, appetite, psychomotor (agitation/retardation), suicidal thoughts)"]
Patient reports their depression is a [select name="depression" value="0|1|2|3|4|5|6|7|8|9|10"]/10; reports their anxiety is a [select name="anxiety" value="0|1|2|3|4|5|6|7|8|9|10"]/10[checkbox memo="include cravings rating" name="include_cravings" value=""][conditional field="include_cravings" condition="(include_cravings).is('')"]; reports their cravings are a [select name="cravings" value="0|1|2|3|4|5|6|7|8|9|10"]/10;[/conditional] and reports they are sleeping on average [select name="sleep" value="0|1|2|3|4|5|6|7|8|9|10"] hours per night with
[checklist name="variable_1" value="no difficulties|difficulties falling asleep| difficulties with frequent awakenings|difficulties staying asleep| difficulties with nightmares "] 
Patient reports [select name="diet" value="good|fair|poor|nutrient deficient"] diet.
[comment memo="Suicidal intent/plan:"] [select value="Patient denies suicidal ideation| Patient endorses suicidal ideation with plan and intent| Patient endorses a history of suicidal ideation, but no current thoughts| Patient endorses suicidal ideation and self-harming behaviors| Patient endorses only self-harming behaviors| Patient refuses to answer questions regarding suicidal ideation| Patient has a history of suicidal ideation and attempt|"]
[comment memo="Psychotic Symptoms: (Hallucinations (visual/auditory), Delusions, Paranoia)"]
[select value="Patient denies a current or former history of Hallucinations (visual/auditory), Delusions, Paranoia| Patient does not endorse current Hallucinations (visual/auditory), Delusions, Paranoia, but reflects a history of symptoms| Patient has current Hallucinations (visual/auditory), Delusions, Paranoia |"][textarea rows="2"]
Patient describes current mood as:[text name="mood" default="***"]
• Past/ Current Psychiatric Diagnosis: [textarea name="psychdx" default="Denies"]
• Previous psychiatric hospitalization: [comment memo="(where and when)"][select value="There is no history of psychiatric hospitalizations|Patient has been psychiatrically hospitalized |"][textarea rows="2"].
• [select value="Previous psychiatric/counseling services includes |Patient has no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"].
• Medications - [select value="Current psychiatric medications include: |Patient is unable to recall current psychiatric medications|"][textarea rows="4"].
•[select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|The patient denies any history of past psychiatric medications trials|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"].
PAST MEDICAL & SURGICAL HISTORY:
[checkbox name="negpmh" value="Patient denies any significant PMH or Surgical history"]
[checkbox name="pospmh" value="Patient past medical history, comordities, current complaints are described as:"]
[textarea name="cc" default="***"]
Patient denies a history of stroke, seizures, MI, dysrhythmias, HLD, HTN, DVT/PE, kidney disease, pancreatitis, liver disease, COPD, cancer, DM, thyroid disease.   
Patient [select name="std" value="denies|endorses|does not disclose"]current concerns about STDs    
Patient [select name="hepc" value="denies|endorses|does not disclose"] current concerns about Hep C  
[comment memo="FEMALE ONLY:"]    
LMP: [date name="3" default=""]
[select name="preg" value="Patient is not seeking to get pregnant in the next year| Patient is seeking to get pregnant within the next year"]
Birth control methods:[text name="bc" default="none"]

LEGAL HISTORY: [comment memo="
jail/prison, probation/parole, charges or pending charges"]
• [textarea name="legal" default="Denies any current or past history of jail/prison, probation/parole, charges or pending charges."]

TRAUMA HISTORY:
• [select value="No history of head injuries or traumatic brain injuries|Past history of traumatic brain injuries resulting from |Patient has an underlying cognitive impairment from |"] [textarea rows="2"]. [select value="Denies history of trauma (sexual, emotional or physical)|Reported having a history of trauma (sexual, emotional or physical) but did not want to elaborate|Reported past traumatic experiences to include |"][textarea rows="2"].

-------------------------------------
PAST MEDICAL HISTORY:    
[textarea name="pastmedhx" default=""]
--------------------------------------
PAST SURGICAL HISTORY
[textarea name="pastsurg" default="sample text"]
--------------------------------------------------------------------
SOCIAL HISTORY:
• Family Constellation/ Support: Patient has [select value="no|1|2|3|4|5|6|7|"] children. Patient is [select name="variable_1" value="single|married|partnered|divorced"]
• Residence:[comment memo="Where/who do you live with"]Patient [select value="has no current housing concerns|is currently in an unstable housing situation related to |"][textarea rows="2"].
• Social Support: Patient identifies [checkbox value="having no one|significant other|extended family|children|friends|church members"][textarea rows="1"] as social-support network.
• Education/employment: Highest level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"]. Patient is able to support self via [select value="current employement|current on disability due to mental health condition|current on disability due to medical condition|current on disability|retirement| illegal means| unable|"][textarea rows="2"].
• Able to support self – Patient is [select value="currently on disability due to mental health condition|currently on disability due to medical condition|currently on disability|currently employed |currently retired from |"][textarea rows="2"].
---------------------------------
FAMILY MEDICAL HISTORY:
Medical
[checkbox name="fmhhx" value="patient denies a family history of diabetes, cancer, thyroid issues, heart disease, hypertension, lung diseases, kidney problems, genetic disorders, stroke, MSK disorders, neurological disorders"]
[textarea name="freefhx" default="Family Medical History includes"]
Psych Family History:
[textarea name="psychfmh" default="Family Psychiatric History includes"]
Substance Use Family History:
[textarea name="sudfmh" default="Family Substance Use History includes"]
-------------------------------
ROS:   NEGATIVE OR STATE +  
CONSTITUTIONAL/NUTRITION: 
[comment memo="fever, weight change, night sweats, poor appetite  
"] [text name="con" default="negative"]
EYES: 
[comment memo="Denies vision changes, blurry vision"][text name="eyes" default="negative"]
ENMT/ HEARING:  
[comment memo="difficulty hearing, ear pain, epistaxis, nasal discharge, sore throat, trouble swallowing, dental problems, or oral mucosal lesions (+HAS DENTURES)"][text name="enmt" default="negative"]
CARDIOVASCULAR: 
[comment memo="Denies chest pain, DOE, palpitations, syncope, pre-syncopal events, or peripheral edema"][text name="cardio" default="negative"]
RESP: 
[comment memo="Denies cough, wheezing, SOB, or pain on inspiration"][text name="resp" default="negative"]
GASTROINTESTINAL: 
[comment memo="Denies N/V/D/C, heartburn, changes in bowel habits, abdominal pain, or appetite changes t"] [text name="gas" default="negative"]
URO/GYN:
[comment memo="Denies dysuria and urinary incontinence , Denies discharge, lesions, tenderness, itching  "][text name="uro" default="negative"]  
MUSCULOSKELETAL:
[comment memo="Denies back/joint pain, joint swelling, muscle cramping, or weakness .Denies neck pain or stiffness"][text name="msk" default="negative"]
SKIN: [comment memo="Denies rashes, itching, lesions"]  [text name="skin" default="negative"] 
NEUROLOGICAL: [comment memo="Denies tingling or numbness, seizures, tremors, or unsteadiness with walking, headaches, dizziness, stroke-like symptoms, memory deficit"] [text name="neuro" default="negative"]     
PSYCH: 
[comment memo="hallucinations, SI, HI, paranoia"][text name="psych" default="negative"]
ENDOCRINE:[comment memo="Denies polyuria, polyphagia, polydipsia, temperature intolerance"]  [text name="endo" default="negative"]   
HEME/ONC: [comment memo="Denies bruising and bleeding"] [text name="hemeonc" default="negative"]   
ALLERGY:
[comment memo="Uticaria, immunocompromised"][text name="allergy" default="negative"]
-------------------------
PHYSICAL EXAMINATION   (NORMAL/ ABNORMAL)
CONSITUTIONAL:
HEAD/FACE:
EYES:
ENMT:
NECK:
RESPIRATORY:
CARDIOVASCULAR:
THORAX:
BREAST:
GASTROINTESTIONAL:
GENITOURINARY:
--FEMALE:
LMP: [date name="variable_2" default=""]
MENSES:
[checkbox name="menses" value="REGULAR|IRREGULAR"]
BIRTH CONTROL METHOD: [text name="bc2" default=""]
PREGNANCY [checklist name="pregn2" value="NO|YES| SUSPECTED"]
-------
LYMPHATIC:
MSK:
DERMATOLOGIC:
NEUROLOGICAL:
- MENTAL STATUS:
- CEREBELLAR COORDINATION:
- CRANIAL NERVES
-MOTOR STRENGTH
-SENSORY
-REFLEXES

NEURO EXAM COMMENTS:
   
GENERAL: well-appearing, cooperative, well nourished, in NAD    
Psych: Normal attention, normal perception, normal mood, normal affect, purposeful motor activity, normal speech, cooperative behavior, thoughts organized and logical and coherent, appropriate thought content    
SKIN: No open wounds or abrasions. Skin warm and dry. Capillary refill in fingers <2 seconds.     
HEAD: Normocephalic, atraumatic.    
EENT:  PERRLA, EOMI, pupils 3mm, sclera and conjunctiva without erythema or injection. Vision grossly normal and gaze aligned appropriately, EACs free of cerumen and discharge. Bilateral TMs pearly grey with visible cone of light, oral mucosa and gums pink and moist, no pharyngeal or tonsillar exudate, uvula midline. No sinus tenderness. No dental abscesses seen.    
NECK: supple. No thyromegaly or lymphadenopathy.  No tracheal deviation.     
CARDIOVASCULAR: RRR, S1 and S2 clear, without clicks, murmurs, or rubs.  No peripheral or generalized edema. Normal pulses in upper and lower extremities.     
PULMONARY: lung fields clear bilaterally. Respirations even and regular. No use of accessory muscles. Air entry normal.     
GASTROINTESTINAL: Soft, non-tender, non-distended. BS present x 4. No masses. No hepatosplenomegaly.     
GENITOURINARY:  No bladder distention. Genital exam deferred.    
MUSCULOSKELETAL: Bilateral upper/lower extremities: symmetric, adequate muscle tone with 5/5 muscle strength, full ROM.  No CVA tenderness.     
NEURO: A x O x 3. Stable gait. See detailed CN below. Point-to-point movement and rapid alternating movement unremarkable. Tandem Walk-Normal, Non-antalgic gait without ataxia or shuffling.  Patellar Reflexes: 2+ bilaterally, bicep reflexes +1 bilaterally     
---------------------------------
Labs Collected on admission:
Non, CBC, CMP, TSH, UA, Urine Drug Screen,[comment memo="optional"]: HIV, HCV
Other: [text name="labtest" default="sample text"]

----------------------------------
MEDICAL PLAN:

[checkbox name="sud2" value="alcohol use disorder|amphetamine use disorder|cannabis use disorder|sedative,hypnotic,anxiolytic use disorder| opioid use disorder| cocaine use disorder| other stimulant use disorder| hallucinogens use disorder| substance use of inhalants| substance use of other psychoactive substances and multiple drug use"]
[checkbox name="continue" value="- Continue [checkbox name="detoxdrug" value="Librum| Ativan|Suboxone| Valium| Ativan PRN"] per protocol
- Monitor s/s for withdrawal    
- Provide PRN medications as indicated
- Educate on the withdrawal process, detox protocol and medication management, and side effects
- Encourage to engage in group sessions, individual therapy sessions, and outings per treatment plan -Coordinate treatment with psychiatric team 
- Engagement in ongoing relapse prevention and aftercare plan
- Continue to monitor during detox and recovery in a protected environment "][checkbox name="nalt" value="[checkbox name="viv" value="educated on naltrexone and vivitrol"]

[checklist name="nic" value="Nicotine Use Disorder"]
[checkbox name="cess" value="[select name="variable_1" value="Cessation Date planned for stay. Behavioral options for quitting reviewed. NRT protocol in place|Behavioral and Pharmacological options for quitting were reviewed. Does not wish to quit at this time"]

[checklist name="variable_htn" value="Hypertension|Monitor Vital Signs Daily . Patient is going through acute withdrawal from ETOH; pt blood pressures will be labile"]
Continue Medication [text name="htnmed" default="sample text"]
Goal for Blood Pressure: Blood pressure <60 year old: <140/80 (with or without diabetes/ CKD); >60 years old <150/90    

[comment memo="OTHER MEDICAL CONDITIONS-PLANS"]
[textarea name="variable_MED" default="OTHER MEDICAL CONDITIONS"]

[comment memo="OTHER PSYCH CONDITIONS-PLANS"]
[textarea name="variable_PSYCH" default="Please defer to psychiatry services"]

Patient is medically cleared to participate in therapeutic programming without medical restriction. [checkbox name="PROGRAM" value="Yes"]
[textarea name="variable_1" default="If not, why"]

Continuing problem List:
[textarea name="PROBLEMLIST" default="Patient should establish care and/or follow up with PCP after discharge regarding health maintenance and preventative health guidelines for ages 19-64 years "]