new patient form

[textarea name="variable_1" default=""]
PSYCH ROS:
Suicidality: [select name="suic3" value="Denies|Active|Passive"] suicidal ideation; [select name="suic4" value="no|loose|firm"] plan [select name="suic7" value="and|but"] [select name="suic5" value="without|with"] intent. [select name="suic6" value="Denies|Endorses|Hx of"] self-injurious behaviors. [select name="sish" value="No hx of suicide attempts|Hx of suicide attempts"].
Mood: [select name="variable_9" value="Transient periods of low mood, but consistent motivation, interest, and socialization. Overall, mood is stable without depressive preoccupations|Depressive|Labile|Elevated"]; [checkbox name="variable_9" value="loss of interest/pleasure|hopelessness|helplessness, feelings of inadequacy|guilt|worthlessness|low energy/fatigue|poor  appetite|irritability|impaired concentration|sleep disturbance|psychomotor changes|almost always depressed|constant mood swings"][select name="variable_11" value="; no s/sx of mania/hypomania|Describes hx of|Endorses"]  [checkbox name="variable_11" value="heightened state of euphoria|heightened senses|intensified experiences|expansive ideas|soaring ambitions|unwavering confidence|boundless energy|thoughts race|rapid and witty speech|constant motion|feel invincible|disregard for sleep/eating/mundane tasks|unchecked impulses|reckless behavior|extravagant spending|risky investments|impulsive relationships|restless agitation|profound exhaustion/depression|psychotic delusions"]
Anhedonia: [select name="variable_173" value="Denies|Present"]
Concentration: [select name="variable_1" value="Occasional distractions, but overall sustained; able to organize/prioritize and complete tasks without stress|Endorses"] [checkbox name="atten" value="difficulty organizing tasks/activities|avoids and procrastinates|forgetful|excessive talking/interrupting conversations|observable pattern of impulsive behavior|difficulty waiting/reduced patience|tendency toward addictive behaviors|inattentive daydreaming|chronic low self-esteem|difficulty with final details|short-tempered with outbursts/tantrums|stubborn, strong-willed|often disobedient|angry often|tendency to be immature|tendency to be or act irrational|trouble seeing someone else`s perspective|trouble with authorities|poor grades|poor school performance|trouble with math/numbers|not achieving up to potential|untended obligations|poor instructional follow through|chronic and problematic loss of items necessary for daily tasks|rushes through/messy work|often not completing work satisfactorily|difficulty negotiating differences|poor sense of responsibility|poor manager of money|spends excessive amount of time due to inefficiency"]
Sleep: [select name="variable_834" value="Adequate and restorative|Poor quality"]
Appetite: [select name="variable_349" value="healthy|fair regarding influence of mood symptoms|poor due to sx"]; [select name="variable_162" value="denies|exhibits"] weight changes. [select value="app1" value="Denies|History of|Admits"] irregular eating patterns.
Energy: [select name="variable_475" value="Good|Fair|Poor"]
Anxiety: [select name="variable_18" value="No excess worry; effectively coping with stress|Self-described anxious worrier"] [checkbox name="variable_18" value="easily overwhelmed|panic attacks|air hunger|rapid heartbeat|dizziness|trembling hands|sweating|tingling sensations in fingers/toes|clenched hands/feet|fainting|vomiting|losing control|afraid to do many things|afraid to go many places|frequently avoids social situations due to fear of doing something stupid or looking silly|fear of flying|fear of heights|fear of closed places|fear of animals|fear of seeing blood|fear of getting an injection|feels disconnected from thoughts|disconnected from feelings|disconnected from surroundings|feeling like observing yourself from outside your body|things seem unreal|feeling like living in a dream world|feeling like living in a movie even when awake"]
Obsessive/Compulsive Behaviors: [select name="variable_19" value="Denies|Admits"] [checkbox name="variable_19" value="weird thoughts that can't be dismissed|rituals that can't be resisted"]
Behavioral Concerns: [select name="variable_2" value="No significant concerns|Endorses"] [checkbox name="variable_2" value="behavioral concerns in school|little respect for parents/teachers or feelings of others|repeated physical and verbal misbehavior|aggression|theft or destruction of property|deception|cheating|manipulation|disregards rules|disrupts family dynamics|trouble at school|involvement with juvenile justice system|shifts blame onto others for problems|uncontrolled angry outbursts that hurt people/destroy property|aggression is out of line|power struggles|persistent anger|argumentative|habitually refuses compliance|unwillingness to adhere to rules or follow instructions|finds pleasure in being disruptive/annoying|consistently pushes boundaries and assigns blame to others|feels misunderstood and victimized|avoids interpersonal contact|does not understand social cues|repetitive stereotyped behaviors|language problems|slow learner|affects performance|causing problems|difficulties with reading|difficulties with writing|difficulties with math"]
Trauma: [select name="variable_22" value="Denies exposure to traumatic events|Positive hx of"] [checkbox name="variable_22" value="physical    abuse|verbal abuse|sexual abuse|traumatic event with haunting memories|flashbacks|nightmares|hypervigilant|easily startled"]
Psychosis: [select name="variable_24" value="Denies AVTOH, delusions, paranoia|Hx of|Exhibits"] [checkbox name="variable_24" value="hearing voices|believing people want to harm|losing touch with reality|feeling watched or plotted against|delusions|hallucinations|thought disorder|bizarre behavior|deficiency in emotional expression|deficiency in motivation|deficiency in thought|deficiency in interpersonal relationships|delusions"]
Substance Hx: [select name="variable_26" value="No hx of addiction/dependence|Hx of"] [checkbox name="variable_26" value="use of alcohol or drugs|suggested to have an alcohol or drug problem|trouble due to alcohol or drugs|troubling symptoms when trying to stop drinking or using a drug"]
Interpersonal Functioning: [select name="variable_27" value="Relationships stable|Admits"] [checkbox name="variable_27" value="style of doing things and relating to people that gets you into the same kind of mess over and over again"]
Side Effects: [select name="variable_32" value="Denies|Admits"]
[checkbox name="variable_32" value="sexual desire is less than it should be"]

MEDICATION TRIALS/RESPONSES: 
[text]

PSYCHIATRIC HISTORY:
Outpatient: [text]
Inpatient: [select name="inpt" value="Admits|Denies"] [text]
History of Violence: [select name="violence" value="Admits|Denies"]
Access to Weapons: [select name="weapons" value="Admits|Denies"]

FAMILY PSYCHIATRIC HISTORY:
[text]

SOCIAL HISTORY:
[select name="relat" value="Single|Married|Divorced|Widowed"].    [select name="lives" value="Lives alone|Lives with SO|Lives with parents|Lives with friend"]. [select name="kids" value="Has|No"] children. [text]
Pregnancy/Pregnancy Prevention: [select name="preg" value="No|Yes"]
Employment: [text]
Developmental/Milestone Delays: [select name="devmile" value="No|Yes"]
Tobacco: [text]
ETOH: [text]
Legal: [select name="legal" value="Admits|Denies"] [text]

MEDICAL HISTORY:
Active Medical Problems: [text]
Surgeries: [text]

ALLERGIES:  
[text]
 
CURRENT MEDICATIONS:  
[text]
 
MENTAL STATUS EXAM:
Appearance: Stated age. Well-groomed. No acute distress. Smooth and coordinated psychomotor movements.
Orientation: Oriented to person, place, time, and situation.
Mood: "[textarea name="mood" default=""]"
Affect: 
Speech: Normal rate/rhythm/tone, spontaneous, unpressured.
Thought Process: Logical, Linear, Age appropriate. 
Associations: Intact.
Thought Content: [textarea name="tht" default=""]
Attention/Concentration: Adequate based on answers to interview questions. 
Memory: Recent and remote memories both intact based on answers to interview questions. 
Language: No evidence of aphasia. 
Judgement: Good
Insight: Good
Fund of Knowledge: Intelligence is average based on answers to interview questions. 

PSYCH ROS:
Suicidality: suicidal ideation; plan intent. self-injurious behaviors. .
Mood: ;
Anhedonia:
Concentration:
Sleep:
Appetite: ; weight changes. irregular eating patterns.
Energy:
Anxiety:
Obsessive/Compulsive Behaviors:
Behavioral Concerns:
Trauma:
Psychosis:
Substance Hx:
Interpersonal Functioning:
Side Effects:


MEDICATION TRIALS/RESPONSES:


PSYCHIATRIC HISTORY:
Outpatient:
Inpatient:
History of Violence:
Access to Weapons:

FAMILY PSYCHIATRIC HISTORY:


SOCIAL HISTORY:
. . children.
Pregnancy/Pregnancy Prevention:
Employment:
Developmental/Milestone Delays:
Tobacco:
ETOH:
Legal:

MEDICAL HISTORY:
Active Medical Problems:
Surgeries:

ALLERGIES:


CURRENT MEDICATIONS:


MENTAL STATUS EXAM:
Appearance: Stated age. Well-groomed. No acute distress. Smooth and coordinated psychomotor movements.
Orientation: Oriented to person, place, time, and situation.
Mood: "
"
Affect:
Speech: Normal rate/rhythm/tone, spontaneous, unpressured.
Thought Process: Logical, Linear, Age appropriate.
Associations: Intact.
Thought Content:

Attention/Concentration: Adequate based on answers to interview questions.
Memory: Recent and remote memories both intact based on answers to interview questions.
Language: No evidence of aphasia.
Judgement: Good
Insight: Good
Fund of Knowledge: Intelligence is average based on answers to interview questions.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.73, 59 form elements, 157 boilerplate words, 13 text boxes, 3 text areas, 11 checkboxes, 32 drop downs, 202 total clicks
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