Psychiatry
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[textarea="variable_1" default="PSYCHIATRIC HISTORY:"]
Past Dx: [checkbox name="variable_1" value="denies|None reported|Unable to obtain, none noted upon review of available records|depression|anxiety|Major Depression|Bipolar Disorder|with psychotic features|“bipolar depression”|Schizophrenia|Schizoaffective Disorder|“bipolar schizophrenia”|Psychotic Disorder|Psychosis NOS|Generalized Anxiety Disorder|Postpartum Depression|Panic Disorder|hx of panic attacks|ADHD|ADHD-dx’d in adulthood|ADHD- dx’d in childhood|Mood Disorder|Adjustment Disorder|Somatoform Disorder|Somatic Symptom Disorder|hx of pseudoseizures|Factitious Disorder|”R/O Factitious Disorder”|Eating Disorder|Anorexia|Bulimia"]
Past Inpatient Tx: [checkbox name="variable_2" value="denies|none reported, none noted per review of available records|None reported,however, chart review indicates|remote history of|past admission to|multiple admissions-"] [checkbox name="variable_3" value="MTMHI"] [textarea name="variable_4" default=""] [checkbox name="variable_5" value="Parthenon"] [textarea name="variable_6" default=""] [checkbox name="variable_7" value="Skyline"] [textarea name="variable_8" default=""] [checkbox name="variable_9" value="Vanderbilt"] [textarea name="variable_10” default=""] [checkbox name="variable_11" value="Moccasin Bend"] [textarea name="variable_12” default=""][checkbox name="variable_13" value="Western State"] [textarea name="variable_14” default=""]
Past Residential/Partial Hospitalization:[textarea name="variable_15" default=" None reported"]
Past Outpatient Tx: [select name="variable_20" value="|Unable to obtain, review of available record is|"]
[checklist name="variable_16" value="Psychiatric provider for evaluation and medication|Psychotherapy/Counseling|Community Mental Health Center|Mental Health Case Management"]
Suicide Attempts: [checkbox name="variable_17" value="Denies|None reported|Unable to obtain, none noted upon review of available records|Hx of suicidal ideation, no prior attempts|Hx of "]
Non-Suicidal Self Injurious Behx: [checkbox name="variable_18" value="Denies|None reported|Unable to obtain, none noted upon review of available records|Hx of cutting for tension-release|Hx of banging head|"]
Hx of Violence/Assaultive Behx: [checkbox name="variable_19" value="Denies|None reported|Unable to obtain, none noted upon review of available record|Hx of"]
Past psychiatric medication trials include: [checkbox value="Has taken psych meds before, cannot recall name| Alprazolam (Xanax)| amitriptyline (Elavil)| amoxapine (Asenden)| aripiprazole (Abilify)| Aripiprazole (Abilify Maintena Injectable)| Aripiprazole lauroxil (Aristada Injectable)|asenapine (Saphris)|atomoxetine (Strattera)|benzotropine (Cogentin)| brexpiprazole (Rexulti )| bupropion (Wellbutrin)| buspirone (BuSpar)| carbamazepine (Tegretol)| clonidine for ADHD (Catapres)| chlordiazepoxide (Librium)| chlorpromazine (Thorazine)| citalopram (Celexa)| clomipramine (Anafranil)| clonazepam (Klonopin)| clorazepate (Tranxene)| clozapine (Clozaril)| diphenhydramine (Benadryl)| desipramine (Norpramin)| desvenlafaxine (Pristiq)| dextroamphetamine (Adderall)/Dexedrine)| dexmethylphenidate (Focalin)| diazepam (Valium)| donepezil (Aricept)|doxepin (Sinequan)| duloxetine (Cymbalta)| escitalopram (Lexapro)| folic acid| fluoxetine (Prozac)|fluoxetine + olanzapine (Symbyax)| fluphenazine (Prolixin)| fluphenazine (Prolixin Injectable)| fluvoxamine (Luvox)| gabapentin (Neurontin) for anxiety/mood| galantamine (Razadyne)| guanfacine for ADHD (Intuniv/Tenex)| haloperidol (Haldol)| Haldol Decanoate Injectable| hydroxyzine (Atarax/Vistaril)| imipramine (Tofranil)| L-methylfolate (Deplin)| lamotrigine (Lamictal)| lisdexamfetamine (Vyvanse)| lithium (Lithobid)| Lorazepam (Ativan)| loxapine (Loxitane)| lurasidone (Latuda)| maprotiline (Ludiomil)| melatonin (OTC)| memantine (Namenda)| mesoridazine (Serentil)| methylphenidate (Ritalin/Concerta/Metadate/Daytrana)|milnacipran (Savella)| mirtazapine (Remeron)| modafinil (Provigil)| molindone (Moban)| nefazodone (Serzone)| nortriptyline (Pamelor)| olanzapine (Zyprexa)| Olanzapine pamoate (Zyprexa Relprevv Injectable)| oxazepam (Serax)| oxcarbazepine (Trileptal)| Paliperidone (Invega Sustenna Injectable)| Paliperidone (Invega Trinza Injectable)| paroxetine (Paxil)| pemoline (Cylert)| perphenazine (Trilafon)| phenelzine (Nardil)| prazepam (Centrax)| prazosin (for nightmares)| prochlorperazine (Compazine)| protriptyline (Vivactil)| quetiapine (Seroquel)| risperidone (Risperdal)| Risperidone (Risperdal Consta Injectible)| rivastigmine (Exelon)| selegiline(Emsam)| sertraline (Zoloft)| temazepam (Restoril)| derealization (Mellaril)| topiramate (Topamax)| tranylcypromine (Parnate)| trazodone (Desyrel)| trifluoperazine (Stelazine)| trimipramine) or multiple)| valproic acid (Depakene/Depakote)| venlafaxine (Effexor)| vilazodone (Viibryd)| vortioxetine (Trintellix)| zaleplon (Sonata)| ziprasidone (Geodon)| zolpidem (Ambien)| zopiclone (Lunesta)|"]
[textarea rows="3"]

Past Dx:
Past Inpatient Tx:
Past Residential/Partial Hospitalization:
Past Outpatient Tx:

Suicide Attempts:
Non-Suicidal Self Injurious Behx:
Hx of Violence/Assaultive Behx:
Past psychiatric medication trials include:

Result - Copy and paste this output: