Mental Health Follow Up

Chief Complaint: 
This is a  [textarea cols=10 rows=1]  year old [checkbox name="variable_9" value="male|female"] presenting for follow up on [checkbox name="variable_1" value="depression|anxiety|panic|ADHD|PTSD|OCD|bipolar disorder|insomnia|psychosis|alcohol use|personality disorder|opioid use|neurocognitive concerns|buprenorphine follow up|vivitrol injection"].

History of Presenting Illness:
[checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="panic" memo="panic" value=""][checkbox name="ADHD" memo="ADHD" value=""][checkbox name="PTSD" memo="PTSD" value=""][checkbox name="OCD" memo="OCD" value=""][checkbox name="bipolar" memo="bipolar disorder" value=""][checkbox name="insomnia" memo="insomnia" value=""][checkbox name="psychosis" memo="psychosis" value=""][checkbox name="alcohol" memo="alcohol" value=""][checkbox name="opioid" memo="opioid" value=""][checkbox name="personality" memo="personality" value=""][checkbox name="neuro" memo="neurocognitive" value=""]
[conditional field="depression" condition="(depression).is('')"]
Depression is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|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"]. There are no reports of [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"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="anxiety" condition="(anxiety).is('')"]
Anxiety is reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|feeling restless/wound up|fatigue|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|irritability|poor concentration|restlessness|loss of appetite"]. There are no reports of [checkbox value="feeling restless/wound up|fatigue|difficulty concentrating|irritability|difficulty falling to sleep|difficulty staying asleep|feeling tired or having little energy|muscle tension|headaches|feeling overwhelmed|irritability|poor concentration|restlessness|loss of appetite"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="panic" condition="(panic).is('')"]
Panic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|palpitations/racing heart|sweating|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|trembling/shaking"]. There are no reports of [checkbox value="palpitations/racing heart|sweating|shaking|shortness of breath|chest pain/tightness|nausea/stomach cramps|numbness/tingling|fear of losing control|closed in feeling|feeling overwhelmed|heat sensations|chills|trembling/shaking"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="ADHD" condition="(ADHD).is('')"]
ADHD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"]. There are no reports of [checkbox value="inattention|careless mistakes|difficulty sustaining attention|problems following conversations|easily side tracked|difficulty organizing tasks/activities|avoidance and procrastination|forgetfulness|easily distracted by unrelated thoughts|fidgeting|inability to relax|excessive talking|difficulty waiting/reduced patience"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="PTSD" condition="(PTSD).is('')"]
PTSD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|annoyance|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"]. There are no reports of [checkbox value="nightmares|flashbacks|intrusive memories/thoughts|avoidance|negative affect|loss of interest|isolation|difficulty experiencing positive emotions|irritability|annoyance|risky/self destructive behaviors|hypervigilance|heightened startle reaction|difficulty concentrating|difficulty falling asleep|difficulty staying asleep"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="OCD" condition="(OCD).is('')"]
OCD symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|recurring thoughts|recurring images|recurring urges|urge to neutralize thoughts|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|excessive time spent thinking or engaging in compulsive behavior"]. There are no reports of [checkbox value="recurring thoughts|recurring images|recurring urges|urge to neutralize thoughts|repetitive behaviors|counting|focusing on geometry|checking|isolation|organizing/aligning objects|hoarding|fear of germs/illness|blinking|touching/tapping|needing constant reassurance|fear of dread|mental rituals|excessive time spent thinking or engaging in compulsive behavior"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="bipolar" condition="(bipolar).is('')"]
Bipolar symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"]. There are no reports of [checkbox value="elevated mood|irritable mood|increased self esteem|loss of sleep|racing thoughts|difficulty keeping up with thoughts|increased desire to speak|feeling more distracted|feeling more energetic|increased desire to engage in activities|agitation|impulsive behaviors|feeling more social/outgoing|increased sex drive|spending money|using drugs/alcohol"][textarea memo="Additional information" rows="1"][/conditional]
[conditional field="insomnia" condition="(insomnia).is('')"]
Insomnia symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when taking up"]. There are no reports of [checkbox value="difficulty falling asleep|difficulty staying asleep|early morning awakening|nightmares|vivid dreams|thrashing in sleep|sleep walking|daytime sedation/fatigue|sleep talking|night terrors|confusion|sleep related eating|hallucinations going to sleep|hallucinations when taking up"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="psychosis" condition="(psychosis).is('')"]
Psychotic symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|delusions of persecution|jealous delusions|somatic delusions|grandiose delusions|religious delusions|thought broadcasting|thought insertion|auditory hallucinations|visual hallucinations|disorganized thoughts|disorganized behaviors|confusion|social isolation|loss of motivation|problems focusing|suicidal thoughts|anxiety"]. There are no reports of [checkbox value="delusions of persecution|jealous delusions|somatic delusions|grandiose delusions|religious delusions|thought broadcasting|thought insertion|auditory hallucinations|visual hallucinations|disorganized thoughts|disorganized behaviors|confusion|social isolation|loss of motivation|problems focusing|suicidal thoughts|anxiety"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="neuro" condition="(neuro).is('')"]
Cognitive symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms|difficulty with complex attention|poor executive functioning|difficulty with short term memory|difficulty with long term memory|motor difficulties|confusion|repetitive behaviors|misplacing objects|difficulty understanding context|difficulty formulating speech|forgetting names/words|loss of interest|confusion|social isolation|loss of motivation|paranoia|visual hallucinations|auditory hallucinations|obsessive behaviors|hoarding behaviors|tremors|night terrors|sleeping during the day|not sleeping at night|agitation|threatening behaviors|inappropriate behaviors"]. There are no reports of [checkbox value="difficulty with complex attention|poor executive functioning|difficulty with short term memory|difficulty with long term memory|motor difficulties|confusion|repetitive behaviors|misplacing objects|difficulty understanding context|difficulty formulating speech|forgetting names/words|loss of interest|confusion|social isolation|loss of motivation|paranoia|visual hallucinations|auditory hallucinations|obsessive behaviors|hoarding behaviors|tremors|night terrors|sleeping during the day|not sleeping at night|agitation|threatening behaviors|inappropriate behaviors"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="alcohol" condition="(alcohol).is('')"]
Alcohol use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of alcohol use|daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work due to drinking|drinking alone|drinking and driving|drinking to fall asleep|escalating alcohol use|tremors|nausea|vomiting|headaches|sweating|anxiety|racing heart|confusion|visual hallucinations|auditory hallucinations|seizures"]. There are no reports of [checkbox value="daily drinking|drinking more than anticipated|inability to cut down on drinking|cravings to drink|blackouts|hangovers|urges to drink|missing work|drinking alone|drinking and driving|drinking to fall asleep|needing to drink more to get the same effect|tremors|nausea|sweating|palpitations|confusion|visual hallucinations|auditory hallucinations|seizures"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="opioid" condition="(opioid).is('')"]
Opioid use symptoms are reported to be [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression of symptoms of opioid use|cravings|urges to use opioids|continued opioid use|use of fentanyl|recent overdose|drowsiness|dizziness|fainting|fatigue|chest pain|difficulty breathing|missing work|irritability|pinpoint pupils|nausea|vomiting|loss of appetite|constipation|diarrhea|stomach cramping|weight loss|racing heart|sweating|chills|palpitations|tearing eyes|yawning|insomnia|bone pain|goose bumps|tremors|leg swelling|yellowing of eyes|loss of libido|confusion|visual hallucinations|auditory hallucinations"]. There are no reports of [checkbox value="no concerning progression of symptoms of opioid use|cravings|urges to use opioids|continued opioid use|use of fentanyl|recent overdose|drowsiness|dizziness|fainting|fatigue|chest pain|difficulty breathing|missing work|irritability|pinpoint pupils|nausea|vomiting|loss of appetite|constipation|diarrhea|stomach cramping|weight loss|racing heart|sweating|chills|palpitations|tearing eyes|yawning|insomnia|bone pain|goose bumps|tremors|leg swelling|yellowing of eyes|loss of libido|confusion|visual hallucinations|auditory hallucinations"].[textarea memo="Additional information" rows="1"][/conditional]
[conditional field="personality" condition="(personality).is('')"]
Personality symptoms are [select value="stable|unchanged|better|somewhat better|somewhat worse|much worse"]. Patient is reporting [checkbox value="no concerning progression interpersonal relationships, impulsivity, behavioral regulation, or affect regulation|unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking"]. There are no reports of [checkbox value="no concerning progression interpersonal relationships, impulsivity, behavioral regulation, or affect regulation|unstable relationships with others|idealizing and devaluing|identity disturbance|feelings of emptiness|affective lability|excessive anger|aggression|efforts to avoid abandonment|impulsive behaviors|suicidality|self injurious behavior|thrill seeking|paranoia|dissociation|attention seeking"].[textarea memo="Additional information" rows="1"][/conditional]

Medication Discussion:
[textarea cols=10 rows=1]  [checkbox name="variable_21" value="continues to report adequate symptom control with the use of the current medications without side effects."] [checkbox name="variable_22" value="reports inadequate symptom control on current medications."] [checkbox name="variable_23" value="Does not report any concerning physical symptoms associated with medication use."] [checkbox name="variable_24" value="Understands to contact me immediately regarding any concern for the possibility of a medication side effects."] [checkbox name="variable_25" value="Does not report any new medications or changes to previous medications for other medical conditions."] [checkbox name="variable_26" value="Reports taking medications regularly without missed doses."] [checkbox name="variable_27" value="Reports taking medications irregularly with missed doses."] [checkbox name="variable_28" value="Reports difficulty picking the medications up from the pharmacy."] [checkbox name="variable_29" value="Reports insurance would not cover prescription."] [checkbox name="variable_30" value="We have discussed the medication regimen and the patient has had the opportunity to ask questions regarding treatment."] [checkbox name="variable_31" value="Encouraged the patient to review medication handout/insert available at the pharmacy or online for complete list of side effects."] [checkbox name="variable_32" value="We discussed time to onset, proper administration, compliance, SE, and mechanism of action in detail."][textarea memo="Additional information" rows="1"]


Assessment:
[textarea cols=10 rows=1]  presents with [checkbox name="variable_40" value="stable mood symptoms with no worsening behaviors, symptom progression, or side effects of the medication regimen."] [checkbox name="variable_41" value="I am not noting any clinical signs to suggest the patient is at an imminent risk in the foreseeable future."] [checkbox name="variable_43" value="Given the sustained symptom improvement and subjective satisfaction with symptom control, no modifications to the current medical treatment is indicated."] [checkbox name="variable_44" value="inadequate response to medications with residual mood symptoms."] [checkbox name="variable_45" value="I will adjust the medications to account for the change in clinical picture."] [checkbox name="variable_46" value="The patient will reach out to me should any symptoms worsen or if the clinical picture changes."] [textarea memo="Additional information" rows="1"]