PFSH

PMHx

Medications from other providers:
[checkbox value="None reported"] 
[textarea rows="5"]
Medical issues/dx:
[checkbox value="No active/past medical issues reported |Self-Care Deficit | Impaired Physical Mobility | Functional Communication Deficit | Addison’s disease | Anemia | Arthritis | Asthma | Cancer |in remission| Celiac disease | Cerebral Palsy | Chronic Kidney Disease (CKD) |Chronic obstructive pulmonary disease (COPD) | Cirrhosis of the liver | Congestive Heart Failure | Constipation | Cornelia de Lange syndrome (CdLS) | Coronary Artery Disease (CAD) | Crohn's disease | Dementia | Down syndrome |Dysphagia| Epilepsy | Fibromyalgia | Fragile X syndrome (FXS) | Gallstones |Gastro-esophageal reflux disease (GERD) | Gout Arthritis | Graves’ disease | Hepatitis B | Hepatitis C |Hearing Deficit| Heart arrhythmia | Hyperlipidemia | Hypertension | Hypothyroidism| Irritable Bowel Syndrome| Migraine headache| Multiple sclerosis| Myasthenia gravis| Obesity| Obstructive sleep apnea| Osteoarthritis (OA)| Osteoporosis| Overactive bladder (OAB)| Parkinson’s Disease| Prader-Willi Syndrome| Rett syndrome| Rheumatoid arthritis| Scoliosis| Smith-Magenis Syndrome| Spina Bifida| Stroke (CVA)| Systemic lupus erythematosus (SLE)| Traumatic Brain Injury (TBI) | Tuberous Sclerosis Complex| Type I Diabetes (Insulin-dependent diabetes mellitus) IDDM| Type II Diabetes (Noninsulin-dependent diabetes mellitus) NIDDM| Ulcerative Colitis | Vitamin D deficiency | Williams Syndrome "][textarea rows="1"]

PSHx
[checkbox value=" No Past Surgical History reported | Ventriculoperitoneal (VP) shunt| Pacemaker implant| Hip arthroplasty "][textarea rows="1"]

PsychHx
[checkbox value="Past Psychiatric Dx: "][checkbox value=" Intellectual Disability |Autism Spectrum Disorder |Attention-Deficit/Hyperactivity Disorder |Psychotic Disorder |Schizophrenia Spectrum Disorder |Bipolar Disorder |Unspecified Mood Disorder |Depressive Disorder |Anxiety Disorder |Obsessive-Compulsive Disorder |Trauma and Stressor-Related Disorder |Eating Disorder | Sleep-Wake Disorder |Substance Related Disorder |Personality Disorder "][textarea rows="1"]
[checkbox value="Past Psychiatric medication trials: "][checkbox value="None Reported"][textarea rows="5"]
Safety:
[checkbox value="Suicidal ideation: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Suicide attempts: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Nonsuicidal Self-Injury: "][checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Hx of Violence/Assaultive Behavior: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Hx of Behavior resulting in Physical Restraints: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Noncompliance with treatment regimen: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Hx of Maladaptive behavior: "] [checkbox value="None Reported |Daytime urinary incontinence (DUI) |Disrobing |Elopement |Emotional outbursts |Fecal incontinence (FI) |Fecal smearing (scatolia) |Food Obsession |Nocturnal enuresis (NE) |Non-compliance |Obsessions, compulsions, and rituals |Physical aggression |Pica |Property destruction |Restrictive Food Intake |Self-injury |Sexually maladaptive behavior |Social Disruption |Threatening behavior |Verbal aggression |Vocal Stimming"][textarea rows="1"]
[checkbox value="Maladaptive behavior triggers: "] [checkbox value="None Reported | Environmental stressors | Medical issues/Biological stressors | Social isolation (lack of social contacts) | Excess environmental stimuli (crowded, loud, over stimulating)| Activity or location transitions | Lack of comprehension of verbal information | Changes of daily routine | Limited access to preferred objects| Limited access to preferred food/beverages| Limited access to preferred caregivers | Changes of support (Caregivers) | Limited access to preferred objects | Limited access to preferred food/beverages | Limited access to preferred caregivers | Limited access to preferred family/social supports "][textarea rows="1"]
[checkbox value="Positive behavioral reinforcers: "] [checkbox value="None Reported |Social activities|Special food and beverages |Desired objects |Verbal Praise |Free time"][textarea rows="1"]
Psychiatric treatment history:
Past Outpatient Tx: 
[checkbox value="None Reported |Bridgewell's The Sovner Center |Bridgewell Counseling Services, Lowell|The Edinburg Center| DDS Special Education Psychiatric services "][textarea rows="1"]
Past Inpatient Tx: 
[checkbox value="None Reported | The Intellectual Disabilities Inpatient Unit at Fuller Hospital |Tewksbury State Hospital|Holy Family Hospital |The Haverhill Pavilion|BayRidge Hospital|MelroseWakefield Hospital "][textarea rows="1"]
Psychological Trauma Hx: 
[checkbox value="None Reported| Physical abuse as an Adult| Physical abuse as an Child | Sexual abuse as an Adult| Sexual abuse as an Child | Emotional abuse as an Adult| Emotional abuse as an Child | Exposure to Traumatic Events"][textarea rows="1"]

PsychFHx:
[checkbox value=" Family psychiatric history unknown|Intellectual Disability |Autism Spectrum Disorder |Attention-Deficit/Hyperactivity Disorder |Psychotic Disorder |Schizophrenia Spectrum Disorder |Bipolar Disorder |Depressive Disorder |Anxiety Disorder |Obsessive-Compulsive Disorder |Trauma and Stressor-Related Disorder |Eating Disorder | Sleep-Wake Disorder |Substance Related Disorder |Personality Disorder "][textarea rows="1"]
[checkbox value="Suicidal ideation: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Suicidal ideation: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Suicide attempts: "] [checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Nonsuicidal Self-Injury: "][checkbox value="None Reported"][textarea rows="1"]
[checkbox value="Hx of Violence/Assaultive Behavior: "] [checkbox value="None Reported"][textarea rows="1"]

SocHx:
Relationship status:[select value="|Married| Single | Divorced | Widowed | Engaged in Long-Term Relationship"]
Children: [select value="||none|1|2|3|4|5|6|7|"][textarea rows="1"]
[checkbox value="Social Supports:"][checkbox value="None Reported | Spouse | Significant other | Brother | Sister |Adult children| Grandchildren| Mother| Father| Uncle|Aunt|Extended family|Neighbors|Friends| Faith group members |Reports limited support system| Reports limited local supports| Reports limited positive supports"][textarea rows="1"][checkbox value="Professional Supports:"]
[checkbox value="Professional Support Access"] [checkbox value="Reports limited access to professional local supports| Reports limited access to professional positive supports"][textarea rows="1"]
[checkbox value="Home health care"] [checkbox value="None Reported|PCA|Visiting Nurse"][textarea rows="1"]
[checkbox value="Case management"][checkbox value="None Reported|Department of Mental Health (DMH) Case management| Department of Developmental Services (DDS) Case management |Vinfen Adult Community Clinical Services (ACCS) |DDS Forensic Mental Health Case management "][textarea rows="1"]
[checkbox value="Residential Services"][checkbox value="None Reported|DDS Shared Living Home Provider | Advocates DDS Adult Group Residential Home|Bridgewell DDS Adult Group Residential Home|Incompass Human Services DDS Adult Group Residential Home|Northeast Arc DDS Adult Group Residential Home|Turning Point Inc. DDS Adult Group Residential Home | NuPath DDS Adult Group Residential | American Training DDS Adult Group Residential Home | 7 Hills DDS Adult Group Residential Home |Vinfen DDS Adult Group Residential Home | Guild for Human Services Group Residential Home | Riverside Residential Group Home |(WCI) Work, Community, Independence, Inc. Residential Group Home | DDS Adult Group Residential Home | DMH Adult Group Residential Home"][textarea rows="1"]
[checkbox value="Therapeutic Day Services"][checkbox value="None Reported| DDS Adult day program |Nupath Adult Day program |Northeast Arc Adult day program | Opportunity Works Adult day program |Bridgewell Roseway Adult day program| American Training Adult day program | Bridgewell Adult day program | Communitas Adult day program | Home Away From Home Adult day program    |  Incompass Human Services Adult day program | Active Day Adult day program"][textarea rows="1"]
Education:
[checkbox value="dropped out before finishing, no GED|high school diploma|GED|Special education school program|undergraduate degree|master's degree|vocational training|some college|doctorate|currently in school"]
[checkbox value="Employment:"] [checkbox value="Employed|currently unemployed|in process of applying for disability|Disabled|on medical leave of absence"][textarea rows="1"]
[checkbox value="Military:"] [checkbox value="no reported history|retired|prior service|Army|Navy|Air Force|Marines|National Guard|Army reserve"][textarea rows="1"]
Legal History: 
[checkbox value="no past legal issues reported |no present active legal issues reported| reports active legal issues related to: |currently on probation| currently on parole| previous incarceration | past history of substance related offenses| past history of violent offenses| past history of sexual offenses"][textarea rows="1"]
[checkbox value="Guardianship & Conservatorship:"][checkbox value="None Reported |Active legal guardianship | Active Rogers Guardianship| Pending Guardianship review by DDS Legal| Activated Health Care Proxy"][textarea rows="1"]
Substance History:
[checkbox value="No active/past substance use issues reported:"] 
[checkbox value="Alcohol:"][checkbox value="None Reported| Hx of Alcohol use disorder|in remission|Social use "][textarea rows="1"]
[checkbox value="Opiates:"] [checkbox value="None Reported| Hx of Opiate use disorder| in remission|Hx of Opiate Overdose "][textarea rows="1"]
[checkbox value="Tobacco:"] [checkbox value="None Reported| Hx of Tobacco use|active use |in remission"]
[textarea rows="1"]
[checkbox value="Cannabis:"] [checkbox value="None Reported| Hx of Cannabis use|active use |in remission "][textarea rows="1"]
[checkbox value="Other Drugs:"] [checkbox value="None Reported| Hx of Prescription drug misuse and abuse| Hx of Stimulant use disorder | Hx of Sedative, Hypnotic, or Anxiolytic Use Disorder |active use |in remission "][textarea rows="1"]