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*Chief Complaint*
Date and Time of Service: [date default="today"] [text size="8"]
Identifying Information:
[text name="name" memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"], [checkbox value="single|married|partnered"] [checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"] who lives with [checkbox value="his|her"] [select value=" significant other|family|alone|is homeless| parents| children| roommate|in a grouphome|"][text size="20"] in [text memo="residing location" size="20"]. [select value="He is his own guardian|She is her own guardian|His guardian is|Her guardian is|They have a DHS guardian |Their guardian is |"][text memo="guardian" size="20"]. [textarea memo="Additional presentation information" rows="5"]

History of Presenting Illness:
[var name="name"] [select value="presents in this outpatient appointment |initially presented to the emergency department "][select value="alone|with family |with significant other |with DHHS worker |with case manager |by police|"][text memo="names" size="20"][select value=" for evaluation and management of | due to reports of |"][checkbox value="his|her"] [text memo="presenting problem" size="20"]. [select value="The patient reports |The family reports |The Guardian reports |The case manager reports |Electronic records indicate |Police report indicates |"][select value="a past psychiatric history of |no history of mental health concerns until |no history of mental health concerns|"][textarea memo="Mental health history" rows="5"]. [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"] [var name="name"]'s depression is characterized as [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"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|”] [checkbox value="his|her"] [select value=" social/work functioning by | “] [textarea rows="1"]. [ checkbox value="She denies current thoughts of suicide and homicide when directly asked.] [ checkbox value="He denies current thoughts of suicide and homicide when directly asked.] [textarea memo="Additional Depression information" rows="5"][/conditional][conditional field="anxiety" condition="(anxiety).is('')"] [var name="name"]anxiety will generally present as [checkbox value="feeling nervous or on edge|excessive or uncontrollable worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [checkbox value="His|Her"] [select value="anxiety is present |”] [select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [checkbox value="His|Her"] [select value="anxiety usually will last for approximately |anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", and is relieved by |"][text size="20]. [textarea memo="Additional Anxiety information" rows="5”] [/conditional][conditional field="mood" condition="(mood).is('')"][select value=" [var name="name"] mood instability has been an issue since |"][text size="20"]. ]. [checkbox value="His|Her"] [select value="disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. ]. [checkbox value="His|Her"] [select value="mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]
[select value="Per patient report,|Per family’s report,|Per electronic records,|"][text size="20"][select value=" they have been | patient has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. [checkbox value="She has|He has"]demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. [checkbox value="His|Her”] presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4”] [/conditional][conditional field="adhd" condition="(adhd).is('')"]
[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] [checkbox value="His|Her"] inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"][/conditional][conditional field="adhd" condition="(adhd).is('')"]
These symptoms have been present since [text memo="before 12yo" size="20"] and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3”] [/conditional]
[conditional field="sleep" condition="(sleep).is('')"] [var name="name"] describes [checkbox value="his sleep as|her sleep as"] [select name="sleepq" value="poor |fair |good|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. [checkbox value="He|She"] estimates getting approximately [text size="4"] hours of [select value="broken |solid |”] sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |”] [textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The patient is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [checkbox value="His|Her"] [select value="past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional][conditional field="sleep" condition="(sleep).isNot('')"] [checkbox value="His|Her"] sleep is reported to be generally good. [/conditional][conditional field="depression" condition="(depression).isNot('')"] [checkbox value="He|She"] denies any marked issues with depression. [/conditional][conditional field="anxiety" condition="(anxiety).isNot('')"] [checkbox value="He|She"] denies any significant issues with anxiety. [/conditional][conditional field="mood" condition="(mood).isNot('')"] [checkbox value="He|She"] denies a history of mania, excessive mood lability, grandiosity, or uncharacteristic risk taking behavior. [/conditional]

[checkbox value="He|She"] [select value="|denies current psychiatric medications|is unable to recall current psychiatric medications|Unable to cover current psychiatric medications with patient due to symptomatic presentation|"][textarea rows="4"]. [checkbox value="He|She"] [select value="is not currently receiving individual counseling/therapy|is currently engaging in individual counseling with |"][textarea rows="1"]. [checkbox value="He|She"] [select value="denies current suicidal ideation or thoughts of self-harm when directly asked|report positive for |denies current suicidal ideation but endorse past thoughts of being better off dead"][textarea rows="1"]. [checkbox value="He|She"] [checkbox value="is able to contract for safety.|denies being able to contract for safety."][textarea rows="1"] [checkbox value="He|She"] [select value="denies having access to guns|report positive for having guns in the home when directly asked | report positive for having guns and other weapons in the home when directly asked "][textarea rows="1"]. [checkbox value=" Writer explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death. Education provided to client about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that patient is unsafe to self or others, provider and patient will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]

Scales and Screening:
PHQ-9: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
GAD-7: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
MDQ: [select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
HITS:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
PC-PTSD:[select value="negative|unable to assess|declined|1|2|3|4"]
AUDIT:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
DAST-10:[select value="negative|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
SLUMS:[select value="N/A|unable to assess|declined|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]

[select value="Previous psychiatric medication trials include but may not be limited to: |The patient has no history of taking psychiatric medications|We were unable to cover previous psychiatric medication trials due to symptomatic presentation|The patient is unable to recall past psychiatric medication trials|"][textarea rows="1"]. [select value="There is no history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="2"]. [select value="Previous psychiatric/counseling services includes |They have no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"]. [checkbox value="He|She"][select value="denies history of diagnosis/treatment for an eating disorder|report positive for a history of diagnosis/treatment for an eating disorder including |Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation|History of diagnosis/treatment of an eating disorder was not assessed in this encounter|"][textarea rows="1"].[checkbox value="He|She"][select value="has no history of thoughts of self-harm|history of thoughts of self harm include |"][textarea rows="2"].[checkbox value="He|She"] [select value="has no history of self harming behavior|History of self-harming behavior includes |Unable to obtain history of self-harming behavior due to symptomatic presentation"][textarea rows="2"]. [checkbox value="He|She"][select value="has no history of head injuries or traumatic brain injuries|has a past history of head injuries resulting from | has a past history of traumatic brain injuries resulting from |has an underlying cognitive impairment from |"][textarea rows="2"]. [checkbox value="He|She"] [select value="denies history of trauma| report having a history of trauma but did not want to elaborate|reports past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="2"]. [checkbox value="He|She"] [select value="report positive for tobacco use consuming approximately |report a past history of tobacco but quit approximately |denies past or current tobacco use|"][textarea rows="1"]. [checkbox value="He|She"][select value=" report current alcohol use consuming approximately |report past alcohol use quitting approximately |denies past or current alcohol use|"][textarea rows="2"]. [checkbox value="He|She"] [select value="denies past recreational substance use|endorses past recreational substance use, but denies current use|reports current recreational substance use in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="4"].

[var name="name"] identifies [checkbox value="having no one as|significant other|extended family|children|friends|church members"][textarea rows="1"] social-support network. They have [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children. [checkbox value="His|Her"] level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"]. [checkbox value="He|She"] is [select value="currently on disability due to their mental health condition|currently on disability due to their medical condition|currently employed |currently unemployed |currently retired from |"][textarea rows="1"]. Financially, [checkbox value="he|she"][select value="identifies no immediate concerns|is burdened by healthcare costs|has concerns related to supporting their family|"][textarea rows="1"]. [checkbox value="His|Her"] source of income is primarily [select value="disability|social security|unemployment|current employment|family support|"][textarea rows="1"]. [checkbox value="He|She"] [select value="has no current housing concerns|reports a currently unstable housing situation related to |"][textarea rows="1"]. [select value="Spirituality was not addressed this visit|Spirituality is identified as |"][select value="|Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"]. Sexual orientation [select value="was not addressed this visit|is identified as |"][select value="|heterosexual|homosexual|bisexual|pansexual|asexual"][textarea rows="1"]. [checkbox value="He|She"] [select value="has no military history|military history includes |Military history was not addressed this visit|"][textarea rows="1"]. [checkbox value="He|She"] [select value="denies current legal concerns|legal concerns include |legal concerns were not addressed due to symptomatic presentation"][textarea rows="1"].

[checkbox value="He|She"][select value="denies knowledge of a family history of mental illness|reports a family history of mental health problems that include |Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="4"]. [checkbox value="He|She"][select value="denies knowledge of a family history of suicides or self-harming behavior|family history of suicides/self-harm includes |Unable to cover family history of suicides/self-harm due to symptomatic presentation|"][textarea rows="2"]. [checkbox value="He|She"][select value="denies knowledge of a family history of substance use issues|Family history of substance use is positive for |Unable to cover family history of substance use issues due to symptomatic presentation|"][textarea rows="4"].
*Chief Complaint*
Date and Time of Service:
Identifying Information:
Patient name is a age-year-old, ethnicity, who lives with in residing location. guardian.Additional presentation information

History of Presenting Illness:
name names presenting problem. Mental health history. depression anxiety sleep mood ptsd adhd autism

. . . .

Scales and Screening:

. . . . . . . . . . .

name identifies social-support network. They have children. level of education is . is . Financially, . source of income is primarily . . . Sexual orientation . . .

. . .

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