New psych eval P

Date and Time of Service: [date default=timestamp]

CC: "[textarea name="variable_2" default=" " rows="1"]" [comment memo="client's own words"]
Client is a [text name="variable_3" default=""] year old [checkbox name="variable_4" value="Caucasian|African American|Hispanic|Asian|Native American|Biracial"][text name="variable_5" default=" "][comment memo="other"] [checkbox name="variable_6" value="male|female"][textarea memo="other" default="" rows="1"] who presents today for [checkbox name="variable_7" value="new psychiatric evaluation|psychiatric follow up|medication management"][textarea memo="other" default="" rows="1"]. 
[checkbox value="Client reports a hx of"] [textarea memo="Past Dx, who diagnosed" name="variable_24" default=" " rows="3"]
[textarea memo="Interval Hx, Onset, duration" default=" " rows="8"]
[textarea memo="Current Rx" name="variable_14" default="Current medications treatment includes " rows="3"] [textarea memo="Tx response" default=" " rows="6"]
[checkbox value="Client complains of the following symptoms"][checkbox name="variable_8" value=" depressed mood|loss of interest/pleasure|weight loss|weight gain|insomnia| hypersomnia|psychomotor retardation|psychomotor agitation|fatigue|feelings of worthlessness/excessive or inappropriate guilt|decreased concentration/indecisiveness|thoughts of death/suicide|excessive anxiety and worry|finds it difficult to control the worry|anxiety and worry are associated with restlessness or feeling keyed up or on edge|being easily fatigued|dificulty concentrating or mind going blank|irritability|muscle tension|sleep disturbance"] [textarea name="variable_9" default="" rows="1"][comment memo="other"] [textarea memo="Previous symptoms" default="" rows="2"] [textarea memo="Onset" default="" rows="2"] [textarea memo="Location" default="" rows="2"] [textarea memo="Duration of symp" default="" rows="2"] [textarea memo="Characteristics" default="" rows="2"] [textarea memo="Aggravating factors" default="" rows="2"] [textarea memo="Relieving factors" default="" rows="2"] [textarea memo="Timing" default="" rows="2"] [textarea memo="severity" default="Today, client rates depression /10, anxiety /10, stress /10, and describes appetite as __poor __fair __good, sleep as __poor __fair __good." rows="4"]
[checkbox value="The client reports the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning." rows="3"] [checkbox value="Client denies any "][checkbox name="variable_15" value="auditory hallucination|visual hallucinations|racing thoughts|excessive worry|suicidal ideation|homicidal ideation|thoughts of self-harm or self-injury|thoughts of harm to others"] [textarea name="variable_28" default=" " rows="1"]

[checkbox value="REVIEW OF SYSTEMS: "][checkbox value="Constitutional: As above. - fevers|Cardio: - Chest pain/palptitations|Resp: - dyspnea|Eyes: - vision changes|Ears: - tinnitus|Endocrine: - heat or cold intolerance"][textarea memo="other" default="" rows="2"]

[checkbox value="PAST PSYCHIATRIC HISTORY: "] [textarea memo="medication trials / as noted in HPI" default="" rows="4"] [checkbox value="Client denies any previous history of"][checkbox value=" psychiatric diagnosis|psychiatric care|hospitalization|outpatient treatment|past suicide attempts|self-injury|violent behavior to others"] [checkbox value="Denies taking any previous psychiatric medications." comment memo="denies med trial"]

[checkbox value="FAMILY PSYCHIATRIC HISTORY: "] [textarea memo="biological, adopted?, unknown?, med trial" default="" rows="2"] [checkbox value="Client denies any family history of"] [checkbox value=" mental health disorders|suicide attempts|completed suicide by any other family members."]

MEDICAL HISTORY: [var name="variable_24"][textarea memo="" default="" rows="2"] [checkbox value="Client denies any history of"][checkbox value="cardiac|respiratory|endocrine|neurological|head injury|HIV|hepatitis|Denies any surgical history."]

CURRENT MEDICATIONS: [var name="variable_14"] [textarea memo="Current med list" default=" " rows="2"] [checkbox value=" Denies taking any other medications|Denies taking herbals or supplements|Denies OTC meds"]

ALLERGIES: [textarea memo="meds/food" default="" rows="2"] [checkbox value="Denies any medication allergies.|Denies any food allergies."]

[checkbox value="SUBSTANCE USE/ ADDICTIVE BEHAVIORS: "][textarea memo="qty,frequency,last drink, past tx" default="" rows="2"] [checkbox value="Denies using nicotine or tobacco products|Denies any alcohol use|Denies using illicit drugs.|Denies using|stimulants|opiates|marijuana|hallucinogens|synthetics|bath salts|club drugs."] [checkbox value="Denies any addictive behaviors such as eating, spending, gaming, gambling, or sexual addictions."]

[checkbox value="PSYCHOSOCIAL: Client is "][checkbox name="variable_22" value="single|married|separated|divorced|in a relationship|widowed|a widower|no children.|1 child.|has children and actively parenting.|has children, not actively parenting.|has grown children."] [checkbox name="variable_17" value="Lives alone.|Lives with partner.|Lives w/ roommates.|Lives with parents.|Currently homeless."] [textarea memo="Lives with other" name="variable_26" default="" rows="1"] [comment memo="EDUCATION"][checkbox name="variable_18" value="No formal education|Elementary school completed|Some highschool-did not graduate|High school graduate|GED|Vocational program completed|College graduate"][textarea memo=" " default="" rows="1"]
[checkbox name="variable_19" value="Unemployed|Employed|on Disability|on Social Security|Reports being financially independent."][textarea memo="job title" name="variable_27" default=" " rows="1"]
[checkbox name="variable_20" value="Denies any current legal issues or pending charges|Client is on probation|Client is on parole|Client has pending charges|Client does not exercise regularly|Client exercises regularly|Client does not eat a healthy diet| Client reports eating a health diet"][textarea memo="which county? ROI?" default="" rows="1"] [checkbox name="variable_21" value="Denies any previous military experience|Client has military experience|Client is a veteran"][textarea memo="comments" default="" rows="1"] [checkbox value="Denies current involvement in church or other religious or spiritual organizations.|Currently involved in church or other spiritual organization."] [textarea memo="Client was raised by , birth order, developmental, Client reports having a good relationship with , Denies any developmental delay." default="" rows="4"] 

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 name="c" value="Steady gait while walking, normal strength bilaterally|"][conditional field="c" condition="(c).is('')"]
[checkbox value="steady gait while walking|unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][/conditional][textarea 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|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"].
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][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 |unable to assess due to cognitive impairment|"][checkbox value="able to name objects|able to repeat phrases"] [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"]

[checkbox value="VITAL SIGNS:"] [textarea memo="HT WT BP HR RR O2 TEMP" default="" rows="1"]

Hair: [select value="normal distribution|thinning hair|balding|hair colored|wearing a hat|wearing a wig"][textarea memo="other" default="" rows="1"]
HEENT: [select value="no abnormal facial, periorbital, or perioral muscle movements|involuntary facial movements visible"][textarea memo="other" default="" rows="1"]
Eyes: [select value="Normal (PERRL)|unequal|irregular|miosis|mydriasis"][textarea memo="other" default="" rows="1"][checkbox value="conjunctiva clear|sclera non-icteric|EOM intact"]
Ears: [select value="hearing is intact|hard of hearing"][textarea memo="other" default="" rows="1"]
Oral mucosa: [select value="moist appearance, pink|dry apperance, pale"][textarea memo="other" default="" rows="1"]
Heart Sounds: [select value="S1, S2 audible, no extra sounds, regular rate and rhythm|S1, S2 audible, irregular rhythm"][textarea memo="other" default="" rows="1"]
Lungs: [select value="Clean in all areas, no adventitious sounds|diminished|absent in some areas|wheezing|find crackles|stridor|rhonchi|rales"][textarea memo="other" default="" rows="1"]
Thyroid: [select value="No palpable abnormalities|palpable nodules|enlarged|irregular"][textarea memo="other" default="" rows="1"]
MSK: [select value="no visible abnormal muscle movements|slow steady gait|slow steady gait with cane|slow steady gait with walker"][textarea memo="other" default="" rows="1"]
Legs: [select value="no edema|pitting edema|non pitting edema"][textarea memo="other" default="" rows="1"]
Skin: [select value="visible skin appears intact|visible skin lesions|multiple skin lesions on face|multiple skin lesions on face and extremities|multiple skin lesions on face, neck, and extremities"][textarea memo="other" default="" rows="1"][checkbox name="variable_23" value="no visible diaphoresis|no visible ecchymosis|excessive dry skin or flaking|echymotic areas|mild tattoos|multiple tattoos|multiple tattoos on arms and face|birthmark|scarring"]

[checkbox value="Diagnostic testing:"] [textarea memo="PHQ-9 HAM-D GAD 7 MDQ" default="" rows="2"]

[textarea memo="DATA REVIEWED: " default=" " rows="1"][checkbox value="I have reviewed the following "][checkbox value="previous records|intake records|transfer records|labs|imaging|referral records"] [textarea default="" rows="1"][comment memo="I obtained collateral information from|family member|staff. I consulted with medical director"]
[checkbox value=" I reviewed PDMP|No report found in client's name.|no concerns.|and found abnormal results."][textarea default="" rows="2"]

ASSESSMENT: [var name="variable_24"] [checkbox value="Client meets DSM-5 Criteria for |Diagnosis: "][textarea memo="other" default="" rows="2"]

PLAN: [textarea memo="meds, psychotherapy, black-box warning" default="Client was educated on the recommendation for treatment, including the following: " rows="8"]
[checkbox value="Client was counseled on benefits, risks, side effects, reviewed alternative treatments, including no treatment, and answered all client questions. "] [checkbox value="Client counseled to notify the clinic/provider of any side effects, adverse reaction, changes in thought, or worsening mood, SI/HI/DTS/DTO, go to ER, or call 911, or crisis hotline."] [checkbox value="Client verbalizes understanding and agrees with the treatment plan."] [checkbox value="The client and/or parent or legal guardian received medication information in the form of a medication information handout."] [checkbox value="Medications have been discussed with parents or legal guardians. "]

FOLLOW UP: [checkbox value="1 week|2 weeks|4 weeks|1 month|2 months|3 months"][textarea memo="other" default="" rows="1"]
Date and Time of Service:

CC: "" client's own words
Client is a year old other other who presents today for other.
Past Dx, who diagnosed
Interval Hx, Onset, duration
Current Rx Tx response
other Previous symptoms Onset Location Duration of symp Characteristics Aggravating factors Relieving factors Timing severity


medication trials / as noted in HPI denies med trial

biological, adopted?, unknown?, med trial

MEDICAL HISTORY: variable_24

CURRENT MEDICATIONS: variable_14 Current med list

ALLERGIES: meds/food

qty,frequency,last drink, past tx

Lives with other EDUCATION
job title
which county? ROI? comments Client was raised by , birth order, developmental, Client reports having a good relationship with , Denies any developmental delay.

Appearance: , other.
Gait and Station / Muscle Strength and Tone: other.
Mood and Affect:
Mood- other.
Affect- other.
Speech: other.
Thought process: other.
Associations: other.
Thought Content: other.
Orientation: other.
Attention and Concentration: other
Memory: other
Language: other
Judgment and Insight:
Judgment- other.
Insight- other
Fund of Knowledge: Based on the answers to interview questions, patient's intelligence is judged to be other


Hair: other
HEENT: other
Eyes: other
Ears: other
Oral mucosa: other
Heart Sounds: other
Lungs: other
Thyroid: other
MSK: other
Legs: other
Skin: other


DATA REVIEWED: I obtained collateral information from|family member|staff. I consulted with medical director

ASSESSMENT: variable_24 other

PLAN: meds, psychotherapy, black-box warning

FOLLOW UP: other

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.54, 156 form elements, 89 boilerplate words, 2 text boxes, 65 text areas, 1 dates, 51 checkboxes, 28 drop downs, 3 variables, 5 comments, 1 conditionals, 298 total clicks
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