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"] 

MENTAL STATUS EXAM: (OBJECTIVE). 
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"]

PHYSICAL EXAM:
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"]