Comprehensive Psychiatry Intake

[remark]ID section start[/remark][checkbox name="id" value="ID:"][conditional field="id" condition="(id).is('ID:')"] [text size="7"], Date: [text size="7"], Name: [text size="40"], Age: [text size="5"], Gender: [select value="Male|Female|Other"][/conditional]

[remark]INF section start[/remark][checkbox name="inf" value="INFORMATION:"][conditional field="inf" condition="(inf).is('INFORMATION:')"] [text size="50"], Refferal: [text size="40"] [/conditional]

[remark]INF section start[/remark][checkbox name="inf" value="SEEN BY:"][conditional field="inf" condition="(inf).is('SEEN BY:')"] SEEN BY DEPT. OF PSYCHIATRY, Dr. [text]
INFORMANT: [text]
REFERRED BY: [text default="none"]
DIAGNOSED CASE OF: [text default="none"] [/conditional]

[remark]CC section start[/remark][checkbox name="cc" value="CHIEF COMPLAINT:"][conditional field="cc" condition="(cc).is('CHIEF COMPLAINT:')"]
[text name="ccdetails" size="75"] [/conditional]

[remark]HPI section start[/remark][checkbox name="hpi" value="HISTORY OF PRESENT ILLNESS:"][conditional field="hpi" condition="(hpi).is('HISTORY OF PRESENT ILLNESS:')"]
[textarea name="hpidetails" cols="75" rows="7"]Psychiatric review of systems is negative for depression, anxiety, psychosis, mania, repetitive behaviors, cognitive symptoms, substance use, personality changes[/textarea][/conditional]

[remark]ROS section start[/remark][checkbox name="ros" value="ROS:"][conditional field="ros" condition="(ros).is('ROS:')"][select name="rosvar" value="NAD|as below"] [/conditional][remark]ROS section-note start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="note" value="NOTE:"][/conditional][conditional field="note" condition="(ros).is('ROS:')&&(note).is('NOTE:')"][textarea cols="50" rows="4"] [/conditional][remark]ROS section-gen start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="gen" value="GENERAL:"][/conditional][conditional field="gen" condition="(ros).is('ROS:')&&(gen).is('GENERAL:')"]no [select value="fever|-"], [select value="chills|-"], [select value="night sweats|-"], [select value="anorexia|-"], [select value="wt loss|-"], [select value="fatigue|-"], [select value="malaise|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-skin start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="skin" value="SKIN:"][/conditional][conditional field="skin" condition="(ros).is('ROS:')&&(skin).is('SKIN:')"]no [select value="rashes|-"], [select value="lesions|-"], [select value="itching|-"], [select value="dryness|-"], [select value="sweating|-"], [select value="hair loss|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-eyes start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="eyes" value="EYES:"][/conditional][conditional field="eyes" condition="(ros).is('ROS:')&&(eyes).is('EYES:')"]no [select value="glasses|-"], [select value="vision problems|-"], [select value="eye discomfort|-"], [select value="eye discharge|-"], [select value="photophobia|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-ent start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="ent" value="ENT:"][/conditional][conditional field="ent" condition="(ros).is('ROS:')&&(ent).is('ENT:')"]no [select value="earache|-"], [select value="ear discharge|-"], [select value="vertigo|-"], [select value="hearing problems|-"], [select value="tinnitus|-"]. [textarea cols="20" rows="1"] no [select value="nose congestion|-"], [select value="nose bleeds|-"]. [textarea cols="20" rows="1"] no [select value="sore throat|-"], [select value="hoarsness|-"], [select value="dysphagia|-"], [select value="odynophagia|-"], [select value="neck lumps|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-ent start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="brst" value="BREAST:"][/conditional][conditional field="brst" condition="(ros).is('ROS:')&&(brst).is('BREAST:')"]no [select value="lump|-"], [select value="pain|-"], [select value="discharge|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-rs start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="rs" value="RS:"][/conditional][conditional field="rs" condition="(ros).is('ROS:')&&(rs).is('RS:')"]no [select value="cough|-"], [select value="sputum|-"], [select value="hemoptysis|-"], [select value="dyspnea|-"], [select value="wheezing|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-cvs start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="cvs" value="CVS:"][/conditional][conditional field="cvs" condition="(ros).is('ROS:')&&(cvs).is('CVS:')"]no [select value="chest pain|-"], [select value="palpitation|-"], [select value="dyspnea|-"], [select value="orthopnea|-"], [select value="PND|-"], [select value="syncope|-"], [select value="edema|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-gi start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="gi" value="GI:"][/conditional][conditional field="gi" condition="(ros).is('ROS:')&&(gi).is('GI:')"]no [select value="abdo pain|-"], [select value="nausea|-"], [select value="vomiting|-"], [select value="diarrhea|-"], [select value="constipation|-"], [select value="bowel habit changes|-"], [select value="jaundice|-"], [select value="hemetemesis|-"], [select value="blood in stool|-"], [select value="tarry stool|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-gu start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="gu" value="GU:"][/conditional][conditional field="gu" condition="(ros).is('ROS:')&&(gu).is('GU:')"]no [select value="painful urination|-"], [select value="GU discharge|-"], [select value="hematuria|-"], [select value="flank pain|-"], [select value="frequent urination|-"], [select value="nocturia|-"], [select value="incontinence|-"], [select value="hesitancy|-"], [select value="difficulty urinating|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-male genital start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="mg" value="MALE GENITAL:"][/conditional][conditional field="mg" condition="(ros).is('ROS:')&&(mg).is('MALE GENITAL:')"]no [select value="testicular pain|-"], [select value="testicular lump|-"], [select value="genital pain|-"], [select value="genital lesion|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-female genital start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="fg" value="FEMALE GENITAL:"][/conditional][conditional field="fg" condition="(ros).is('ROS:')&&(fg).is('FEMALE GENITAL:')"]no [select value="amenorrhea|-"], [select value="dysmenorrhea|-"], [select value="menorrhagia|-"], [select value="vaginal bleeding|-"], [select value="pelvic pain|-"], [select value="genital pain|-"], [select value="genital lesion|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-msk start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="msk" value="MUSCULOSKELETAL:"][/conditional][conditional field="msk" condition="(ros).is('ROS:')&&(msk).is('MUSCULOSKELETAL:')"]no [select value="back pain|-"], [select value="joint pain|-"], [select value="joint swelling|-"], [select value="muscle pain|-"], [select value="muscle weakness|-"], [select value="stiffness|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-psych start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="psych" value="PSYCH:"][/conditional][conditional field="psych" condition="(ros).is('ROS:')&&(psych).is('PSYCH:')"][textarea cols="20" rows="1"] [/conditional][remark]ROS section-neuro start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="neuro" value="NEURO:"][/conditional][conditional field="neuro" condition="(ros).is('ROS:')&&(neuro).is('NEURO:')"]no [select value="headache|-"], [select value="head injury|-"], [select value="weakness|-"], [select value="numbness|-"], [select value="tingling|-"], [select value="tremor|-"], [select value="seizure|-"], [select value="syncope|-"], [select value="dizziness|-"], [select value="cognitive sx|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-hemat start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="hemat" value="HEMATOLOGICAL:"][/conditional][conditional field="hemat" condition="(ros).is('ROS:')&&(hemat).is('HEMATOLOGICAL:')"]no [select value="easy bruising|-"], [select value="easy bleeding|-"], [select value="lymphadenopathy|-"]. [textarea cols="20" rows="1"] [/conditional][remark]ROS section-endo start[/remark][conditional field="rosvar" condition="(ros).is('ROS:')&&(rosvar).is('as below')"][checkbox name="endo" value="ENDO:"][/conditional][conditional field="endo" condition="(ros).is('ROS:')&&(endo).is('ENDO:')"]no [select value="cold intolerance|-"], [select value="heat intolerance|-"], [select value="sweating|-"], [select value="excessive thirst|-"], [select value="excessive hunger|-"], [select value="excessive urine|-"], [select value="weight changes|-"]. [textarea cols="20" rows="1"] [/conditional]

[remark]PAST H/O section start[/remark][checkbox name="past" value="HISTORY OF PAST ILLNESS:"][conditional field="past" condition="(past).is('HISTORY OF PAST ILLNESS:')"]
[textarea cols="75" rows="3"] [/conditional]

[remark]FAMILY H/O section start[/remark][checkbox name="fam" value="FAMILY HISTORY:"][conditional field="fam" condition="(fam).is('FAMILY HISTORY:')"]
[textarea cols="75" rows="3"] [/conditional]

[remark]SOCIAL H/O section start[/remark][checkbox name="soc" value="SOCIAL HISTORY:"][conditional field="soc" condition="(soc).is('SOCIAL HISTORY:')"]
[textarea cols="75" rows="3"] [/conditional]

[remark]MEDICATIONS H/O section start[/remark][checkbox name="meds" value="MEDICATIONS:"][conditional field="meds" condition="(meds).is('MEDICATIONS:')"]
[textarea cols="75" rows="3"] [/conditional]

[remark]ALLERGIES H/O section start[/remark][checkbox name="allerg" value="ALLERGIES:"][conditional field="allerg" condition="(allerg).is('ALLERGIES:')"]
[textarea cols="75" rows="2"] [/conditional]

[remark]PE section start[/remark][checkbox name="pealt" value="EXAMINATION FINDINGS:"][conditional field="pealt" condition="(pealt).is('EXAMINATION FINDINGS:')"]
[textarea name="a1" default=".\nHeight cm Weight Kg BMI \nno Pallor | no Cyanosis | no Clubbing | no Lymphadenopathy |\nno Edema | no Malnutrition | no Dehydration\nTemperature Normal | Pulse rate /min, regular\nRespiratory rate /min\nBlood pressure Right Upper Limb mmHg | Left Upper Limb mmHg\nLMP if female pt\n\nSystemic examination findings:\nRS: AEBE, no rales, no ronchi\nCVS: s1,s2 present, no murmur\nAS: pa soft, no guarding/rigidity, no organomegaly\nCNS: no focal abnormalities" cols="70" rows="15"] [/conditional]

[remark]PE section start[/remark][checkbox name="pe" value="PHYSICAL EXAM:"][conditional field="pe" condition="(pe).is('PHYSICAL EXAM:')"][textarea fillable="true" cols="75" rows="12"]Temp:******  Pulse: ****** RR:****** BP:****** SPO2:******
Gen:******
RS: ***aebe***, ***no rales***, ***no ronchi***
CVS: ***s1,s2 present***, ***no murmur***
AS: ***pa soft***, ***no gaurding/rigidity***, ***no organomegaly***
CNS:
cn 2-12: ***intact***
motor: ***no wasting***, ***tone normal***, ***power 5/5 at all joints***
reflexes: ***+2 at all joints***, ***plantar flexor***
sensory: ***normal pain and joint position sensation***
gait: ***normal***
-----[/textarea] [/conditional]

[remark]MSE section start[/remark][checkbox name="mse" value="MENTAL STATUS EXAMINATION:"][conditional field="mse" condition="(mse).is('MENTAL STATUS EXAMINATION:')"] 
Appearance: [select value="alert and oriented to time, place and person|OBTUNDED|DISORIENTED|HYPERALERT|-"], [select value="well kempt|POORLY KEMPT|appropriately dressed|INAPPROPRIATELY DRESSED|appropriately groomed|INAPPROPRIATELY GROOMED|DISHEVELED|-"], [select value="normal posture|SLUMPED|RIGID|TENSE|-"]. [textarea cols="20" rows="1"]
Behavior: [select value="calm|RESTLESS|AGITATED|RETARDED|PECULIAR|IMPULSIVE|-"], [select value="interactive|WITHDRAWN|-"], [select value="eye contact good|eye contact AVOIDANT|eye contact INTENSE|eye contact FLEETING|-"], [select value="No EPSE|EPSE PRESENT|-"], [select value="No abnormal involuntary movements|ABNORMAL INVOLUNTARY MOVEMENTS PRESENT|-"]. [textarea cols="20" rows="1"]
Attitude: [select value="cooperative|HOSTILE|OVER FRIENDLY|SECRETIVE|EVASIVE|SUSPICIOUS|APATHETIC|EASILY DISTRACTED|FOCUSED|DEFENSIVE|DEMANDING|SEDUCTIVE|-"]. [textarea cols="20" rows="1"]
Speech: [select name="spontn" value="spontaneous|NON-SPONTANEOUS|MUTISM|-"], [select name="rt" value="N reaction time|INCR REACTION TIME|DECR REACTION TIME|VARIABLE|-"], [select name="rate" value="normal rate|SLOW|POVERTY|PAUCITY|RAPID|OVERTALKATIVE|PRESSURE|-"], [select name="vol" value="normal volume|LOUD|SOFT|WHISPHER|MONOTONE|-"], [select name="rhythm" value="clear rhythm|SLURRED|HESITANT|APHASIC|-"].[textarea cols="20" rows="1"]
Mood reported as: [textarea cols="20" rows="1"], inferred as-[select value="euthymic|NOT REPORTED|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"]
Affect: quality: [select value="euthymic|ANXIOUS|DEPRESSED|DYSPHORIC|IRRITABLE|ELEVATED|EXPANSIVE|ELATED|EUPHORIC|ANGRY|HOSTILE|INDIFFERENT|DETACHED|ANIMATED|-"], [select value="range normal|BROAD|RESTRICTED|-"], [select value="intensity normal|EXPANSIVE|BLUNTED|FLAT|LABILE|-"], [select value="congruent|INCONGRUENT|-"]. [textarea cols="20" rows="1"] 
Thought form: [select value="coherent|INCOHERENT|CANNOT BE ASSESSED|NOT ENOUGH SAMPLE|-"], [select value="logical and goal directed|-|CIRCUMSTANTIAL|TANGENTIAL|LOOSENING|FLIGHTS OF IDEAS"]. [select value="-|NEOLOGISM|BLOCKING|VERBAL PERSEVERATION"]. [textarea cols="20" rows="1"]
Thought content: [select value="no delusion on current evaluation|DELUSION PRESENT|CANNOT BE ASSESSED|-"], [select value="no active suicidal ideations at present| SUICIDAL IDEATIONS PRESENT|DEATH WISHES PRESENT|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Perception: [select value="no hallucination on current evaluation|HALLUCINATION|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Insight: [select value="present|PARTIAL|POOR|MOSTLY BLAMES OTHERS|DIFFICULTY IN ACKNOWLEDGING PRESENCE OF PSYCHIATRIC SYMPTOMS|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Judgment: [select value="intact|IMPAIRED|CANNOT BE ASSESSED|-"]. [textarea cols="20" rows="1"]
Cognition: [select value="Clinically intact|ABNORMALITIES PRESENT|PENDING|CANNOT BE ASSESSED|-"]. [textarea default="normal attention, concentration, intact ability to recall recent and remote information, normal abstraction" cols="50" rows="3"] [/conditional]

[remark]Labs H/O section start[/remark][checkbox name="labs" value="LABS:"][conditional field="labs" condition="(labs).is('LABS:')"]
[textarea cols="75" rows="3"] [/conditional]

[remark]DD section start[/remark][checkbox name="dd" value="DIFFERENTIAL DIAGNOSIS:"][conditional field="dd" condition="(dd).is('DIFFERENTIAL DIAGNOSIS:')"][textarea fillable="true" cols="75" rows="13"]Drugs:******
Infective:******
Vascular:******
Inflammatory:******
Nutritional:******
Endocrine:******
Metabolic:******
Degenerative:******
Trauma:******
Tumor:******
Seizure:******
Structural:******
Other:******
Psychogenic:******
[/textarea] [/conditional]

[remark]Plan section start[/remark][checkbox name="plan" value="PLAN OF MANAGEMENT:"][conditional field="plan" condition="(plan).is('PLAN OF MANAGEMENT:')"][textarea fillable="true" cols="75" rows="10"]Problems:******
Diagnostic plan:******
Psychopharmacological Rx plan:******
Psychological Rx plan:******
[/textarea] [/conditional]