Assessment & Plan Elements
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Diagnostic Impression
Axis I: ??
Axis II: ??
Axis III: ??
Axis IV: ??
Axis V: GAF ??
*DEPRESSION*
Depressed mood (x2 weeks) YES
Depressed mood (x2 weeks) NO
Decreased interest (x2 weeks) YES
Decreased interest (x2 weeks) NO
Details: ??
Weight or appetite loss/gain YES
Weight or appetite loss/gain NO
Insomnia/hypersomnia YES
Insomnia/hypersomnia NO
Retarded/agitated motor activity YES
Retarded/agitated motor activity NO
Fatigue or energy loss YES
Fatigue or energy loss NO
Feels worthless/guilty YES
Feels worthless/guilty NO
Concentration/indecisive YES
Concentration/indecisive NO
Thoughts of death/suicide YES
Thoughts of death/suicide NO
*MANIC EPISODE*
Euphoric mood (x1 week) YES
Euphoric mood (x1 week) NO
Irritable Mood (x1 week) YES
Irritable Mood (x1 week) NO
Details: ??
Grandiosity or exaggerated self-esteem YES
Grandiosity or exaggerated self-esteem NO
Reduced need for sleep YES
Reduced need for sleep NO
Increased talkativeness YES
Increased talkativeness NO
Flight of ideas or racing thoughts YES
Flight of ideas or racing thoughts NO
Easily distracted YES
Easily distracted NO
Psychomotor agitations/increased activityYES
Psychomotor agitations/increased activity NO
Poor judgement YES
Poor judgement NO
*GAD*
Excessive anxiety/worry (x6 mo) YES
Excessive anxiety/worry (x6 mo) NO
Trouble controlling these feelings YES
Trouble controlling these feelings NO
Details: ??
Feels restless, edgy, keyed up YES
Feels restless, edgy, keyed up NO
Tires easily YES
Tires easily NO
Trouble concentrating YES
Trouble concentrating NO
Irritability YES
Irritability NO
Increased muscle tension YES
Increased muscle tension NO
Trouble sleeping YES
Trouble sleeping NO
*PANIC ATTACK*
Sudden severe fear or discomfort that peaks within 10 minutes YES
Sudden severe fear or discomfort that peaks within 10 minutes NO
Details: ??
Chest pain or other chest discomfort YES
Chest pain or other chest discomfort NO
Chills or hot flashes YES
Chills or hot flashes NO
Choking sensation YES
Choking sensation NO
Derealization/depersonalization YES
Derealization/depersonalization NO
Dizzy, lightheaded, faint, or unsteady YES
Dizzy, lightheaded, faint, or unsteady NO
Fear of dying YES
Fear of dying NO
Fears loss of control/becoming insane YES
Fears loss of control/becoming insane NO
Heart pounds, races, or skips beats YES
Heart pounds, races, or skips beats NO
Nausea or other abdominal discomfort YES
Nausea or other abdominal discomfort NO
Numbness or tingling YES
Numbness or tingling NO
Sweating YES
Sweating NO
Shortness of breath/smothering feeling YES
Shortness of breath/smothering feeling NO
Trembling YES
Trembling NO
*AGORAPHOBIA*
Anxiety about being in place/situation where escape is difficult or causes embarrassment YES
Anxiety about being in place/situation where escape is difficult or causes embarrassment NO
If a panic attack occurred, help might not be available YES
If a panic attack occurred, help might not be available NO
Details:??
Avoids these situations or places YES
Avoids these situations or places NO
Endures them with distress YES
Endures them with distress NO
Requires a companion in situation YES
Requires a companion in situation YES
*SPECIFIC PHOBIA*
Strong, persistent fears that seem excessive or unreasonable that are cued by specific object or situations YES
Strong, persistent fears that seem excessive or unreasonable that are cued by specific object or situations NO
Details:??
Phobic stimulus provokes anxiety response/panic attack YES
Phobic stimulus provokes anxiety response/panic attack NO
Realizes fear is unresonable YES
Realizes fear is unresonable NO
Avoids stimulus/endures with distress YES
Avoids stimulus/endures with distress NO
*SOCIAL PHOBIA*
Strong repeated fears of a social or performance situation that involves facing strangers or being watched by others YES
Strong repeated fears of a social or performance situation that involves facing strangers or being watched by others NO
Details:??
Phobic stimulus causes anxiety/panic YES
Phobic stimulus causes anxiety/panic NO
Fears showing anxiety/embarrass self YES
Phobic stimulus causes anxiety/panic NO
Realizes fear is unreasonable YES
Realizes fear is unreasonable NO
Avoids stimulus/endures it with distress YES
Avoids stimulus/endures it with distress NO
Distressed about having phobia YES
Distressed about having phobia NO
*OCD*
Recurring thoughts, impulses or images that intrude into awareness and cause marked distress or anxiety YES
Recurring thoughts, impulses or images that intrude into awareness and cause marked distress or anxiety NO
Feel the need to repeat physical behaviors or mental behaviors YES
Feel the need to repeat physical behaviors of mental behaviors NO
Ideas not just about ordinary problems YES
Ideas not just about ordinary problems NO
Tries to ignore/suppress/neutralize ideas by thoughts or behavior YES
Tries to ignore/suppress/neutralize ideas by thoughts or behavior NO
Insight that ideas = product of own mind YES
Insight that ideas = product of own mind NO
Behaviors occur as response to obsession or strictly applied rules YES
Behaviors occur as response to obsession or strictly applied rules NO
Aim of behaviors is to reduce or eliminate distress/prevent something dreaded YES
Aim of behaviors is to reduce or eliminate distress/prevent something dreaded NO
Behaviors not realistically related to the events they counteract or are excessive for that purpose YES
Behaviors not realistically related to the events they counteract or are excessive for that purpose NO
Realizes it is unreasonable/excessive YES
Realizes it is unreasonable/excessive NO
Causes severe distress YES
Causes severe distress NO
Takes up time (> hour per day) YES
Takes up time (> hour per day) NO
Interferes w/usual routine or functioning YES
Interferes w/usual routine or functioning NO
Diagnostic Impression
Axis I: ??
Axis II: ??
Axis III: ??
Axis IV: ??
Axis V: GAF ??
*DEPRESSION*
Depressed mood (x2 weeks) YES
Depressed mood (x2 weeks) NO
Decreased interest (x2 weeks) YES
Decreased interest (x2 weeks) NO
Details: ??
Weight or appetite loss/gain YES
Weight or appetite loss/gain NO
Insomnia/hypersomnia YES
Insomnia/hypersomnia NO
Retarded/agitated motor activity YES
Retarded/agitated motor activity NO
Fatigue or energy loss YES
Fatigue or energy loss NO
Feels worthless/guilty YES
Feels worthless/guilty NO
Concentration/indecisive YES
Concentration/indecisive NO
Thoughts of death/suicide YES
Thoughts of death/suicide NO
*MANIC EPISODE*
Euphoric mood (x1 week) YES
Euphoric mood (x1 week) NO
Irritable Mood (x1 week) YES
Irritable Mood (x1 week) NO
Details: ??
Grandiosity or exaggerated self-esteem YES
Grandiosity or exaggerated self-esteem NO
Reduced need for sleep YES
Reduced need for sleep NO
Increased talkativeness YES
Increased talkativeness NO
Flight of ideas or racing thoughts YES
Flight of ideas or racing thoughts NO
Easily distracted YES
Easily distracted NO
Psychomotor agitations/increased activityYES
Psychomotor agitations/increased activity NO
Poor judgement YES
Poor judgement NO
*GAD*
Excessive anxiety/worry (x6 mo) YES
Excessive anxiety/worry (x6 mo) NO
Trouble controlling these feelings YES
Trouble controlling these feelings NO
Details: ??
Feels restless, edgy, keyed up YES
Feels restless, edgy, keyed up NO
Tires easily YES
Tires easily NO
Trouble concentrating YES
Trouble concentrating NO
Irritability YES
Irritability NO
Increased muscle tension YES
Increased muscle tension NO
Trouble sleeping YES
Trouble sleeping NO
*PANIC ATTACK*
Sudden severe fear or discomfort that peaks within 10 minutes YES
Sudden severe fear or discomfort that peaks within 10 minutes NO
Details: ??
Chest pain or other chest discomfort YES
Chest pain or other chest discomfort NO
Chills or hot flashes YES
Chills or hot flashes NO
Choking sensation YES
Choking sensation NO
Derealization/depersonalization YES
Derealization/depersonalization NO
Dizzy, lightheaded, faint, or unsteady YES
Dizzy, lightheaded, faint, or unsteady NO
Fear of dying YES
Fear of dying NO
Fears loss of control/becoming insane YES
Fears loss of control/becoming insane NO
Heart pounds, races, or skips beats YES
Heart pounds, races, or skips beats NO
Nausea or other abdominal discomfort YES
Nausea or other abdominal discomfort NO
Numbness or tingling YES
Numbness or tingling NO
Sweating YES
Sweating NO
Shortness of breath/smothering feeling YES
Shortness of breath/smothering feeling NO
Trembling YES
Trembling NO
*AGORAPHOBIA*
Anxiety about being in place/situation where escape is difficult or causes embarrassment YES
Anxiety about being in place/situation where escape is difficult or causes embarrassment NO
If a panic attack occurred, help might not be available YES
If a panic attack occurred, help might not be available NO
Details:??
Avoids these situations or places YES
Avoids these situations or places NO
Endures them with distress YES
Endures them with distress NO
Requires a companion in situation YES
Requires a companion in situation YES
*SPECIFIC PHOBIA*
Strong, persistent fears that seem excessive or unreasonable that are cued by specific object or situations YES
Strong, persistent fears that seem excessive or unreasonable that are cued by specific object or situations NO
Details:??
Phobic stimulus provokes anxiety response/panic attack YES
Phobic stimulus provokes anxiety response/panic attack NO
Realizes fear is unresonable YES
Realizes fear is unresonable NO
Avoids stimulus/endures with distress YES
Avoids stimulus/endures with distress NO
*SOCIAL PHOBIA*
Strong repeated fears of a social or performance situation that involves facing strangers or being watched by others YES
Strong repeated fears of a social or performance situation that involves facing strangers or being watched by others NO
Details:??
Phobic stimulus causes anxiety/panic YES
Phobic stimulus causes anxiety/panic NO
Fears showing anxiety/embarrass self YES
Phobic stimulus causes anxiety/panic NO
Realizes fear is unreasonable YES
Realizes fear is unreasonable NO
Avoids stimulus/endures it with distress YES
Avoids stimulus/endures it with distress NO
Distressed about having phobia YES
Distressed about having phobia NO
*OCD*
Recurring thoughts, impulses or images that intrude into awareness and cause marked distress or anxiety YES
Recurring thoughts, impulses or images that intrude into awareness and cause marked distress or anxiety NO
Feel the need to repeat physical behaviors or mental behaviors YES
Feel the need to repeat physical behaviors of mental behaviors NO
Ideas not just about ordinary problems YES
Ideas not just about ordinary problems NO
Tries to ignore/suppress/neutralize ideas by thoughts or behavior YES
Tries to ignore/suppress/neutralize ideas by thoughts or behavior NO
Insight that ideas = product of own mind YES
Insight that ideas = product of own mind NO
Behaviors occur as response to obsession or strictly applied rules YES
Behaviors occur as response to obsession or strictly applied rules NO
Aim of behaviors is to reduce or eliminate distress/prevent something dreaded YES
Aim of behaviors is to reduce or eliminate distress/prevent something dreaded NO
Behaviors not realistically related to the events they counteract or are excessive for that purpose YES
Behaviors not realistically related to the events they counteract or are excessive for that purpose NO
Realizes it is unreasonable/excessive YES
Realizes it is unreasonable/excessive NO
Causes severe distress YES
Causes severe distress NO
Takes up time (> hour per day) YES
Takes up time (> hour per day) NO
Interferes w/usual routine or functioning YES
Interferes w/usual routine or functioning NO

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