Laura FU Appt

HISTORY OF PRESENTING PROBLEM
*Chief Complaint*

Patient presents today
[checkbox name="11" value="via telemedicine|in person|alone|accompanied by parent|accompanied by partner|"]

for a follow-up evaluation for

[checkbox name="12" value="ADHD|impulsivity|inattention|depression|anxiety|panic|OCD|Binge eating disorder|insomnia|mood disorder"]

At last visit, patient   

[checkbox name="13" value="had no changes|medication was added|medication was decreased|medication was discontinued|medication was increased"]

[textarea name="variable_1"default="sample text"].    
Reports symptoms of     

[checkbox name="14" value="low mood|insomnia|anxiety|panic|OCD|ADHD|binge eating|hyperactivity|impulsivity"]

Reports    symptoms

[checkbox name="15" value="have worsened|stayed the same|improved|and is currently experiencing"]

Reports    currently    experiencing  

[checkbox name="16" value="difficulty concentrating|difficulty focusing|hyperactivity|insomnia|difficulty falling asleep|difficulty staying asleep|increase in anxiety|improved anxiety|panic attacks|low mood|improved mood|increase in appetite|lack of appetite"]

Currently in Therapy:
[select value="denied|currently in"][textarea rows="1"]
Current Suicidal Ideation:
[select value="denied|yes with no plan|yes with a plan|not suicide but thoughts of being better off dead"][checkbox value="contracts for safety|cannot contract for safety"] [textarea rows="1"]

*Review of Systems* 
The patient identifies the following symptoms: [comment memo="General"][checkbox value="denies|endorses|significant weight changes|fevers|chills|fatigue"][textarea memo="other"default=""rows="1"]
Neurological-[checkbox value="Headaches|weakness|disturbed sleep| dizziness|syncope|seizures|denied|Normal sensation"][textarea memo="other" default="" rows="1"]
Psychiatric -[checkbox value="Denies significant changes in mood|no    changes    in    affect|appropiate    thought content|No suicidal or homicidal ideation|Reports normal sleep patterns|No    changes    in    appetite|No significant anxiety or panic symptoms"]
Cardiovascular-[checkbox value="No chest pain|palpitations|shortness of breath|Reports regular exercise routine without any limitations"]
GI -[checkbox value="Upset stomach|nausea|constipation|heatburn|denied"][textarea memo="other" default="" rows="1"].
Respiratory-[checkbox value="No cough|shortness of breath|wheezing|Denies any history of respiratory infections or asthma exacerbations"]
Genitourinary- [checkbox value="No dysuria|hematuria|frequency|urgency|incontinence| Denies any genital or urinary tract discomfort"]

All other systems negative


Appearance:[select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default=""rows="1"]
Gait and Station / Muscle Strength and Tone: [select value="Steady gait while walking, normal strength bilaterally|"][checkbox value="unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|rigid|normal strength bilaterally|weakness noted in"][text    area memo="other"default=""rows="1"]
Mood and Affect:
Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default=""rows="1"]
Affect- [checkbox value="sad|tearful|labile|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"]
Speech:[select value="Normal rate and rhythm, not pressured|pressured|paucity|soft"][textarea memo="other"default=""rows="1"]
Thought process:[select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"]
Associations:[select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"]
Thought Content:[select value="no evidence of delusions,|"][select value="no evidence of response to internal stimuli,|"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other"default="" rows="1"]
Orientation:[select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on patient's answers to interview questions|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |"][select value="|, able to name objects|[select value="|, able to repeat phrases"][select value="|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Judgment and Insight:
    Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"]
    Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]

[textarea default="" rows="1"][comment memo="



ASSESSMENT
Patient is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance use disorder|cognitive impairment|impulsivity|mood lability|alcohol dependence|opioid dependence|autism spectrum disorder|inattention|impulsivity|hyperactivity"][text    area memo="other" default="" rows="1"] [textarea memo="other" default="" rows="1"]. 
Prognosis is [select value="good|fair|poor"] 

PLAN:

The following interventions were ordered/recommended this appointment:
[checkbox name="variable_1" value="No    changes    were    made|decrease    medication|discontinue    medication|Add    medication"]
[textarea rows="5"] 

[textarea rows="5"]
[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. "]


Follow-up in 
[checkbox name="variable_1" value="2-4    weeks    or    prn|1-3    months    or    prn|3    months    or    sooner    if    needed| Continue in therapy"]