intake pull down

[date name="variable_1" default="03/24/2020"]

Patient Info:
[text name="variable_1" default="sample text"]
Chief Complaint/Source:
[textarea name="variable_1" default="sample text"]
HPI
[textarea name="variable_1" default="sample text"]
Past Medical History:
[textarea name="variable_1" default="sample text"]
Past Psychiatric/Hospitalization History:
[textarea name="variable_1" default="sample text"]
Suicide Attempts
[textarea name="variable_1" default="sample text"]
Social History:
[textarea name="variable_1" default="sample text"]
Substance Use:
[textarea name="variable_1" default="sample text"]
Legal History:
[textarea name="variable_1" default="sample text"]
Family History:
[textarea name="variable_1" default="sample text"]
Allergies:
[textarea name="variable_1" default="sample text"]
Current Medications:
[textarea name="variable_1" default="sample text"]
Medication Trials:
[textarea name="variable_1" default="sample text"]
Current Treaters:
[textarea name="variable_1" default="sample text"]
Seizure History:
[text name="variable_1" default="sample text"]
History of Head Injury:
[text name="variable_1" default="sample text"]

Review of Symptoms

Medical ROS:
[textarea name="variable_1" default="sample text"]

Depression (at least 4 for 2 weeks): 
[checkbox name="variable_1" value="Sleep disturbances|Decreased interest in activities pleasure in activities|Decreased Guilt/Worthlessness|Decreased energy/Fatigue|Decreased concentration|Decreased appetite|Increased appetite|Psychomotor retardation|Psychomotor agitation|Thoughts of death"]
[textarea name="variable_1" default="sample text"]


Dysthymia (2 out of 6 for at least 2 years)
[checkbox name="variable_1" value="Decreased or increased appetite|Decreased concentration|Hopelessness|Decreased energy|Worthlessness|Sleep disturbances"]
[textarea name="variable_1" default="sample text"]

Manic Episode (Lasting at least one week or hospitalization was necessary)
[checkbox name="variable_1" value="Persistently elevated mood|Persistently irritable mood"]
Manic Episode cont.(3 or more of the following symptoms during the mood episode, 4 or more symptoms if mood is only irritable)
[checkbox name="variable_1" value="Distractibility|Involvement in high risk or pleasurable activities|Grandiosity or inflated self-esteem|Flight of ideas or racing thoughts|Increased goal directed activity|Sleep deficit|Talkativeness"]
[textarea name="variable_1" default="sample text"]

Generalized Anxiety (Symptoms for at least 6 months
[checkbox name="variable_1" value="Excessive worry occurring more days than not|Difficulty controlling worry"]
GAD cont. (3 of the following symptoms)
[checkbox name="variable_1" value="Muscle tension|Fatigue|Difficulty concentrating|Restless or feeling on edge|Irritability|Sleep disturbance"]
[textarea name="variable_1" default="sample text"]

Panic Disorder
[checkbox name="variable_1" value="recurrent unexpected panic "]
(with at least 4 of the following symptoms)
[checklist name="variable_1" value="Palpitations|Chest pain|Nausea|SOB|Choking sensation|Dizziness|Paresthesias|Hot/cold waves|Fear of dying|Fear of going crazy|Sweating|Shaking|Derealization/depersonalization"]

At least one panic attack has been followed by 1 month of one of the following:
[checklist name="variable_1" value="Fear of another panic attack occurring|persistent worry about the implications of the attack|change in behavior because of the panic attacks"]
[textarea name="variable_1" default="sample text"]

Agoraphobia:
[checkbox name="variable_1" value="Fear of being in places where escape may be difficult or embarrassing|Situations are avoided or endured with marked distress"]
[textarea name="variable_1" default="sample text"]


PTSD (Symptoms lasting at least 6 months)
[checklist name="variable_1" value="Experienced traumatic event"]
[checklist name="variable_1" value="Re-experiences event via memories, dreams and/or flashbacks|Avoids stimuli associated with the event|Negative beliefs about self|Negative beliefs about the world|Diminished interest in activities|Sleep disturbances|Irritability|Difficulty concentrating|Hyper-vigilance|Exaggerated startle response"]
[textarea name="variable_1" default="sample text"]

Attention deficit hyperactivity disorder 
(At least 6 symptoms from criteria 1 or 2 if under 17 yo, At least 5 if over 17 yo)

Criteria 1: Organization/Inattention
[checkbox name="variable_1" value="Can't organize tasks|Loses things needed for tasks|Has problems finishing tasks|Poor focus|Easily distracted|Doesn't listen|Forgets easily|Makes careless mistakes|Avoids tasks requiring concentration"]

Criteria 2: Impulsivity/Hyperactivity
[checkbox name="variable_1" value="Talks too much|Blurts out answers|Interrupts others|Can't play quietly|Fidgets and squirms|Leaves seat|Restlessness|Always on the go|Can't wait for their turn"]

Criteria 3:
[checklist name="variable_1" value="Some symptoms present before the age of 12"]

Criteria 4:
[checklist name="variable_1" value="Symptoms occur in 2 or more settings"]
[textarea name="variable_1" default="sample text"]

Substance Use Disorder:
[checklist name="variable_1" value="Tolerance to substance|Symptoms of substance withdrawal|Loss of control of substance use"]
[textarea name="variable_1" default="sample text"]

OCD:
[textarea name="variable_1" default="sample text"]

Psychosis:
[textarea name="variable_1" default="sample text"]

Eating Disorder:
[textarea name="variable_1" default="sample text"]

Personality Disorders:
[textarea name="variable_1" default="sample text"]

Other Notes:
[textarea name="variable_1" default="sample text"]



Mental Status Exam:
Level of Consciousness: 
[select name="Level of Consciousness" value="alert|drowsy|confused"]
Orientation:
[select name="variable_1" value="Oriented x3|Oriented x2|Oriented x1|Oriented x0"]


General Appearance:[select value="appears to be of chronological age|appears younger than chronological age|appears older than chronological age|unknown"].
Attitude:[select value="cooperative|friendly|uncooperative|irritated but not to the level of anger|angry|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn"].
Grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|unknown"].
Clothing: [select value="clean|dirty|unkempt|neat|tidy|meticulous|worn out|skillfully applied|unconventional|fashionable|unknown|professional"],[select value="appropriate for season| inappropriate to season|unknown"],[select value="appropriate for setting| inappropriate for setting|unknown"].
Hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
Build: [select value="average height|tall|short|unknown"],[select value="average weight|thin|overweight|obese|underweight|unknown"].
Facial expression: [select value="casual(normal)|bland|flat|mobile(rapid changes)|angry|unknown"].
Abnormal movements: [select value="none|grimaces|tics|twitches|foot tapping|rocking back and forth|hand wringing|ritualistic behavior|mannerisms|posturing|nail biting|chewing movements|echopraxia|tardive dyskinesia|catatonic|unknown"].
Rate/gait: [select value="normal|hyperactive|slow|retarded|agitated|hesitant|propulsive|shuffling|dancing|ataxic|uncoordinated|unknown"].
Coordination: [select value="normal/no problems|awkward|clumsy|agile|falling easily|needed assistance|bed ridden|uses wheelchair|uses walker|unknown"].
Posture: [select value="quietly seated|relaxed|stooped|combative|hyperactive|agitated|rigid|stiff|shaky|slouched|bizarre movements|posturing|crouching|erect|restless|unknown"].
Speech: [select value="normal rate and volume|pressured|monotonous|quiet|emotional|loud|forgetful|whispering|yelling|accented|impoverished|neologisms|aphasia|global aphasia|Broca's aphasia|Wernicke's aphasia|dysarthia|preservation|sterotypy"].
Speech clarity: [select value="clear|slurred|mumbled|lisping|stuttering|inaudible|incoherent|long pauses"].
Speech quantity: [select value="within normal limits|responds only to questions|scant|mute|verbose|repetitive"].
Mood observed: [select value="euthymic|expansive|euphoric|anxious|depressed|tearful|labile|flat|happy|sad|irritated|angry|enraged|guilty|other (describe)"].
Affect: [select value="euthymic|full range of affect|broad|appropriate|constricted|blunted|flat|labile|anhedonic|blunted|emotional withdrawal|excited"].
Mood/affect congruence: [select value="congruent|not congruent"].
Eye contact: [select value="eye contact good|eye contact fair|eye contact avoidant|unknown"].
Cognition/Memory - overall functioning: [select value="within normal limits|grossly intact|below average|above average|short-term memory loss|long-term memory loss|amnesia|anterograde amnesia|retrograde amnesia| history of head trauma|transient global amnesia"].
Cognition/Memory - abstraction: [select value="normal ability to abstract|difficulty with abstract thought|inability for abstract thought"].
Thought form and flow: [select value="logical, relevant, and goal orientated|not logical, relevant, and goal orientated|past orientated|scattered|impoverished|racing thoughts|circumstantial|perservations|flight of ideas|illogical|hopeful|remorseful|enthusiastic|incoherent|neologism|distractable|tangential|overvalued ideas|excited|poverty of though|word salad|clang associations|slow reaction|rapid reaction|doubting|indecisive|blocking|spontaneous|pressured|"].
Thought perception: [select value="within normal limits|illusions|hallucinations|denationalization|derealization"]
Thought content: [select value="within normal limits|thought withdrawal|thought insertion|paranoia|thought broadcast|suspiciousness|grandiose delusions|somatic delusions|delusional guilt|nihilistic delusions|ideas of reference|ideas of inference|magical thinking"].
Insight: [select value="good|fair|poor"]. Judgment: [select value="good|fair|poor"].

Suicidality: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk for self harm as evidenced by patient's self-report of [select value="not having any|having a"] suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

Self-injurious behavior: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk for self-injurious harm as evidenced by patient's self-report of [select value="not having any|having a"] self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent:[textarea cols="20" rows="1" default= "No action taken."]

Homicidality/bodily injury towards others: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Patient is currently assessed to be at [select value="no|low|moderate|high"] risk of being a harm to others as evidenced by patient's self-report of [select value="not having any|having a"] homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a homicidal ideation/plan/intent: [textarea cols="20" rows="1" default= "No action taken."]

Assessment:
[textarea name="variable_1" default="sample text"]

Diagnosis:
[textarea name="variable_1" default="sample text"]

Treatment Plan

REVIEW/MANAGEMENT
[checkbox value="I reviewed PMP|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"]

 [checkbox value="I discussed risks vs. benefits, as well as side effects with the patient, reviewed alternative treatments, including no treatment, and answered any questions. "][checkbox value="Medications have been discussed with parents or legal guardians. "][checkbox value="The patient and/or parent or legal guardian received medication information in the form of a medication information handout. "]

The following interventions were ordered/recommended this appointment:

Medications:
[textarea name="variable_1" default="sample text"]
Therapy:
[textarea name="variable_1" default="sample text"]
Follow-up:
[textarea name="variable_1" default="sample text"]
Labs:
[textarea name="variable_1" default="sample text"]
Referral:
[textarea name="variable_1" default="sample text"]

[checkbox name="variable_1" value="Patient/and or parent or legal guardian understands limits of confidentiality."]
[checkbox name="variable_1" value="Informed consent given for medication regime."]
[checkbox name="variable_1" value="Patient advised if any homicidal or suicidal ideation to call 911 or go to the nearest ER."]