PSYCH EVAL

Date of Service:[date name="variable_1" default="today"]
Name :[text name="variable_2" default=""]
D.O.B. :[date name="variable_3" default="08-24-1990"]
Date of admission:[date name="variable_4" default="08-24-2023"]

Reason for admission: [checkbox name="variable_5" value="Alcohol Use Disorder|Opioid Use Disorder|Stimulant Use Disorder|Depression|Anxiety|General Anxiety Disorder|"][text name="variable_6" default="" rows="1"][comment memo="Other Reasons"]

Allergies: [checkbox name="variable_7" value="NKDA|Penicillin|Environmental|Latex|Peanut|"][text name="variable_8" default=""][comment memo="Other allergies"]

History of Present Illness:
The client arrived at [checkbox name="variable_9" value="NW|TR for the stabilization of|AUD|OUD|SUD"]

after the relapse started over a [checkbox name="variable_10" value="week|month|year ago|none"]

He/She is feeling [checkbox name="variable_11" value="generally well|no current concerns|highly Anxious|shaky|tremors|nausea/vomiting|headache|fatigue|dizziness|irritable|insomnia.|slept well last night|slept only for a few hours"]

Medication list:[text name="variable_12" default=""]

Previous anti- cravings medications: [checkbox name="variable_13" value="Naltrexone|Acamprosate|Gabapentin|Disulfiram|Topiramate|"][text name="variable_14" default=""][comment memo="Other"]

Stopped taking it due to GI symptoms. [checkbox name="variable_15" value="Feeling sick|"] [text name="variable_16" default=""][comment memo="Other"]

Used only for a [checkbox name="variable_17" value="few days|weeks|months."]

PMHx:[textarea name="variable_18" default=""]

HIV/Hepatitis risk: [checkbox name="variable_19" value="None|"][text name="variable_20" default=""][comment memo="Other"]

Psych Hx: [checkbox name="variable_21" value="No formal Dx|Anxiety|depression  |psychosis | cognitive impairment |impulsivity |mood lability |autism spectrum disorder|Bipolar disorder|PTSD"]

Hospital admissions: [comment memo="Add history of admission"]
[textarea name="variable_22" default=""]
[checkbox name="variable_23" value="None"]

Current suicide or self-harm intent: [checkbox name="variable_24" value="Denies
|Suicidal thoughts present with no actual plans"]

Homicidal Ideation: [checkbox name="variable_25" value="Denies|"][text name="variable_26" default=""][comment memo="Other"]

Surgery: [checkbox name="variable_27" value="None|"][comment memo="Add surgical history"][textarea name="variable_28" default=""]

Family history of mental health : [checkbox name="variable_29" value="None|"][text name="variable_30" default=""][comment memo="History"]

Family history of suicidal behaviour: [checkbox name="variable_31" value="None|"][text name="variable_32" default=""][comment memo="History"]

Relationship status:  [text name="variable_33" default=""][comment memo="Details"]

Financial/ employment status: [text name="variable_34" default=""][comment memo="Details"]

Substance Use History:
Alcohol: [checkbox name="variable_35" value="None"]
[checkbox name="variable_36" value="Started:"][text name="variable_37" default=""]
[checkbox name="variable_38" value="Amount of usual use:"][text name="variable_39" default=""]
[checkbox name="variable_40" value="Last Used:"][text name="variable_41" default=""]
[checkbox name="variable_42" value=""][textarea name="variable_43" default=""][comment memo="Add other alcohol intake hx"]

Marijuana: [checkbox name="variable_44" value="None"]
[checkbox name="variable_45" value=""][textarea name="variable_46" default=""][comment memo="Add other hx"]

Benzodiazepines: [checkbox name="variable_47" value="None"]
[checkbox name="variable_48" value=""][textarea name="variable_49" default=""][comment memo="Add other hx"]

Stimulants/Cocaine: [checkbox name="variable_50" value="None"]
[checkbox name="variable_51" value=""][textarea name="variable_52" default=""][comment memo="Add other hx"]

Opioids/fentanyl: [checkbox name="variable_53" value="None"]
[checkbox name="variable_54" value=""][textarea name="variable_55" default=""][comment memo="Add other hx"]

Other: [checkbox name="variable_56" value="None"]
[checkbox name="variable_57" value=""][textarea name="variable_58" default=""][comment memo="Add other hx"]

Smoking: [checkbox name="variable_59" value="None"]
[checkbox name="variable_60" value=""][textarea name="variable_61" default=""][comment memo="Add other hx"]

Overdose hx: [checkbox name="variable_62" value="None"]
[checkbox name="variable_63" value=""][textarea name="variable_64" default=""][comment memo="Add other hx"]

Seizure hx: [checkbox name="variable_65" value="None"]
[checkbox name="variable_66" value=""][textarea name="variable_67" default=""][comment memo="Add other hx"]

Withdrawal experience/complications: [checkbox name="variable_68" value="nausea|tremors|anxiety|panic attacks|leg pain/body pain|restlessness|headache|nausea|Insomnia|Irritable|Sweats"]

Substance use treatment history: [checkbox name="variable_69" value="None|"]
[textarea name="variable_70" default=""][comment memo="Add other hx"]


Current addiction services: [checkbox name="variable_73" value="None|"]
[textarea name="variable_74" default=""][comment memo="Add other hx"]

ROS:
Any concerns with orientation, or memory: [checkbox name="variable_75" value="No complaints|"]
[textarea name="variable_76" default=""][comment memo="Add other hx"]


CNS: [checkbox name="variable_91" value="no complaints|Migraine|Siezure"]

Labs: will be reviewed when AV

Objective:
Gait and Station: [checkbox name="variable_93" value="Steady gait while walking"]

Appearance:[select name="variable_94" value="stated age|older than stated age|younger than stated age| neat|disheveled|"]
[comment memo="Other"]
[textarea name="variable_95" default=""]

Mood: [checkbox name="variable_96" value="euthymic |depressed |anxious |angry |irritable |happy |fluctuating|"]
[comment memo="Other"]
[textarea name="variable_97" default=" "]

Affect: [select name="variable_98" value=" sad |tearful |anxious |flattened |restricted |irritable |happy |full range|congruent to mood."]

Speech: Normal rate and rhythm, not pressured

Thought process: [checkbox name="variable_99" value="Logical and linear|age-appropriate,|circumstantial"]

Associations: [checkbox name="variable_100" value="Intact|Loose|tangential"]

Thought Content: no evidence of delusions, no evidence of response to internal stimuli, no
suicidal ideation or intentions, no homicidal ideation or intentions

Orientation: Oriented to person, place, and time

Attention and Concentration: Adequate attention and concentration based on answers to interview
question

Memory: Recent and remote memories both intact based on patient's answers to interview
questions

Judgment: [select name="variable_101" value="fair|good|poor|impulsive"]

Insight : [select name="variable_102" value="fair|good|poor"]

no psychotic phenomena: [checkbox name="variable_103" value="denies intrusive or racing thoughts."]

Assessment: [checkbox name="variable_104" value="DSM 5-Alcohol use disorder-severe|DSM- 5- Opioid Use Disorder|DSM- 5- Stimulant Use Disorder"]