hpi

HISTORY OF PRESENTING PROBLEM

*Chief Complaint*
Date and Time of Service:[date default="today"] [text size="8"]
 is see in this intake for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
[textarea memo="quotes" default="" rows="1"]
*Interval History*
 presents as [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"] [textarea memo="other" default="" rows="1"]
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"] [textarea memo="other" default="" rows="1"]
 notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"] [textarea memo="other" default="" rows="1"]
History of Presenting Illness:
[textarea rows="6"]
Current Psychiatric Medications:
[textarea rows="4"]
Currently in Therapy:
[select value="denied|currently in "] [textarea rows="1"]
Current Suicidal Ideation:
[select value="denied|yes with no plan|yes with a plan|not suicide but thoughts of being better off dead"][checkbox value="contracts for safety|cannot contract for safety"] [textarea rows="1"]
Guns in the home / access to guns:
[select value="denied|yes "][textarea rows="1"][checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that  is unsafe to self or others, provider and  will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide"]
Current Substance Use:
[select value="Denied|Reports positive for "][checkbox value="alcohol|tobacco|cannabis|opiate use|methamphetamine use"] [textarea rows="1"]
 identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"] [textarea memo="other" default="" rows="1"]
Other systems:
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"] [textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heatburn|denied"] [textarea memo="other" default="" rows="1"].
All other systems negative
*Past/Family/Social History* [comment memo="Include for 99214 + 99215"]
[textarea rows="3"]
Social Supports:
[checkbox value="none|significant other|extended family|children|friends|church members"]
Marital status:
[select value="married|partnered|single|"][textarea rows="1"]
Children:
[select value="0|1|2|3|4|5|6|7|"][textarea rows="1"]
Lives:
[select value="with significant other|alone|with children|with extended family|with parents|"][textarea rows="1"]
Works:
[select value="on disability|retired|unemployed|works as a |"][textarea rows="1"]
Financial Concerns:
[select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"]
Source of Income:
[select value="disability|social security|unemployment|work|family support|"][textarea rows="1"]
Housing Concerns:
[select value="none|unstable housing situation related to |"][textarea rows="1"]
Spirituality:
[select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"]
Sexual Orientation:
[select value="heterosexual|homosexual|bisexual|declined to answer|unable to assess due to symptomatic presentation|"]
Military:
[select value="denied|retired |active |"][textarea rows="1"]
Legal Concerns:
[select value="denied|"][textarea rows="1"]
HISTORIES:
[comment memo="All Information below is historical and not to be counted as part of the progress note"]
Previous Psychiatric Medications:
[textarea rows="1"]
Previous Psychiatric Hospitalization (s):
[select value="none|"][textarea rows="1"]
Previous Therapy:
Family History of Substance Use or Psychiatric Illness:
History of Suicide Attempt (s):
Family History of Suicide Attempt (s) or Completed Suicide:
History of Abuse:
[checkbox value="Time spent in psychotherapy: "][checkbox value="16-37 min"][comment memo="30 min 90833"][checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
[checkbox value="Focus of psychotherapy: "][checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
[checkbox value="Modality: "][checkbox value="insight oriented|supportive|behavioral modification"][textarea memo="other" default="" rows="1"]
REVIEW/MANAGEMENT
[checkbox value="I reviewed the following notes: "][textarea default="" rows="1"][checkbox value=" I reviewed the following labs, imaging, consults: "][textarea default="" rows="1"][checkbox value=" I obtained collateral information from "][textarea default="" rows="1"][checkbox value=" I consulted with "][textarea memo="individual and reason for consultation" default="" rows="1"][checkbox value="I reviewed PMP|and found no abnormal results.|and found abnormal results "][textarea default="" rows="1"]
The following interventions were ordered/recommended this appointment:
[textarea rows="5"] [checkbox value="I discussed risks vs. benefits, as well as side effects with , reviewed alternative treatments, including no treatment, and answered any questions. "][checkbox value="Medications have been discussed with parents or legal guardians. "][checkbox value=" and/or parent or legal guardian received medication information in the form of a medication information handout. "]
Medication List:
[textarea rows="5"]
Allergies:
Significant Medical Issues:
ASSESSMENT
 is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"].  would benefit from [checkbox value="initiation of psychopharmaceutical intervention|continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|initiation of psychotherapy|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"]. Prognosis is [select value="good|fair|poor"] considering  [select value="remains adherent to|actively engages in"] medication and therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"]. [checkbox value=" strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment"][textarea memo="strengths" rows="1"]. [textarea rows="5"]
GOALS
[checkbox value="- will report score on PHQ-9 of 8 or less within 3 months: Initiated this appointment "][textarea rows="1"][checkbox value="
- will report score on GAD-7 of 8 or less within 3 months: Initiated this appointment "][textarea rows="1"][checkbox value="
- will reduce nicotine intake by 50% within one month: Initiated this appointment "][textarea rows="1"][checkbox value="
- will experience 6+ hours of uninterrupted sleep per night within 3 months: Initiated this appointment "][textarea rows="1"][checkbox value="
- will report impact of cognitive impairment as mild/resolved within 3 months: Initiated this appointment "][textarea rows="1"]
PLAN:
Adult Medical History
[checklist name="Q1" value="Not Applicable|Abortion|Alcoholism|Anemia|Arthritis|Asthma|Brain Injury|Cancer, NOS|Chronic Pain|constipation|COPD|Crohn's Disease|Dental Disorders|Dizziness|Diabetes Mellitus|Drug Dependence|Emphysema|Epilepsy|Fatigue|Fibromyalgia|Hepatitis|Hypertension|HIV Infection|Irritable Bowel Syndrome|Motor Neuron Disease|Obesity|Renal Disease|Shingles|Sleep Disorder|STD|Stroke/CVA|Tuberculosis|Thyroid Disorders"]
[text]
Childhood Medical History
[checklist name="Q2" value="Not Applicable|Chicken Pox|Ear Infections|Ear Tubes|Eating Disorder|Encopresis|Enuresis|Measles|Mononucleosis|Mumps|Polio|Rheumatic Fever|Rubella|Scarlet Fever|Smallpox|Whooping Cough"]
Trauma History
Childhood Abuse
[checklist name="Q38" value="Verbally|Physically|Sexually|Physical neglect|Cultural deprivation|Subjected to ethnic discrimination"]
Treatment History
Substance Abuse History
Family Medical History
[checklist name="Q17" value="Alcholism|Drug dependence|Anxiety Disorder NOS|Depression|Mental (Psychiatric) Disorder|Suicide Completion|Family history of ADHD|Asthma|Cancer, NOS|Coronary artery disease|Diabetes mellitus|Heart disease|Hypertension|Seizure disorder|Thyroid disorder"]
Family History
[checklist name="Q17" value="Mental disability|Recorded family history of mental illness (not retardation)|Previous psychiatric treatment|Parents divorced"]
Mother
[text] Age
[select name="Q18" value="Alive|Deceased"]
Father
[select name="Q19" value="Alive|Deceased"]
[text] # Siblings born
 is [text default="youngest, oldest, middle, etc."]
Family history of alcoholism
[select name="Q20" value="Father|Mother|Both parents"]
[checklist name="Q21" value="Death in the family"]
Current Family and Significant Relationships
[checklist name="Q22" value="Living environment secure and supportive|Lack of social support from family|Lack of social support from friends|Lack of companionship|Interpersonal problems|Family problems|Family problems - Disruption|Family problems - Estrangement|Family problems - Physically or sexually abused by family member|ETOH use affecting relationships with others|Drug use affecting personal relationships"]
[checklist name="Q23" value="Living independently with spouse|Living with parents|Living with significant other"]
Spouse
[select name="Q24" value="Alive|Deceased"]
[text] # Children living
[text] # Children deceased
[checklist name="Q25" value="Single|Unmarried, living together|Recent breakup with significant other|Currently married"]
[text] # Total number of marriages
[checklist name="Q26" value="Separated"]
[checklist name="Q27" value="Divorced"]
[text] # Divorced times
[checklist name="Q28" value="Recently divorced"]
[checklist name="Q29" value="Widowed"]
[checklist name="Q30" value="Annulment"]
Assessment of current relationship (if applicable)
[checklist name="Q31" value="Interpersonal relationship problems"]
Life circumstance event
[checklist name="Q32" value="Physically abused"]
[checklist name="Q33" value="Sexually abused"]
[checklist name="Q34" value="Abused as child"]
[checklist name="Q35" value="Verbally berated, harassed, intimidated"]
[checklist name="Q36" value="Neglected as child "]
[checklist name="Q37" value="Abuse/neglect"]
Dangerousness Assessment
[checklist name="Q39" value="Previous suicide attempt|Suicidal ideation|Suicidal plan|Suicidal intent|Homicidal ideation|Homicidal plan|Homicidal intent|Repetitive self injurious|Access to weapons/guns in home"]
HPI
Date::[date default="today"] [text size="6"]
Pt is see in this intake for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"]
Pt remains [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"][textarea memo="other" default="" rows="1"].
Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"][textarea memo="other" default="" rows="1"]
The Pt notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"][textarea memo="other" default="" rows="1"]
Scales and Screening:
PHQ-9: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
GAD-7: [select value="unable to assess|declined|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
*Review of Systems* [comment memo="Include for 99213 thru 99215"]
The Pt identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"][textarea memo="other" default="" rows="1"]
Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"][textarea memo="other" default="" rows="1"]
GI - [checkbox value="Upset stomach|nausea|constipation|heartburn|denied"][textarea memo="other" default="" rows="1"]
*Past/Family/Social History*
PHYSICAL HEALTH HISTORY
Appearance: [select value="stated age|older than stated age|younger than stated age"], [select value="neat|disheveled"][textarea memo="other" default="" rows="1"]
Gait and Station / Muscle Strength and Tone: [select value="Steady gait while walking, normal strength bilaterally|"][checkbox value="unsteady gait while walking|clumsy|unable to ambulate|in bed|in wheelchair|assisted by cane|assisted by walker|rigid|spastic|normal strength bilaterally|weakness noted in "][textarea memo="other" default="" rows="1"]
Mood and Affect:
Mood- [checkbox value="euthymic|depressed|anxious|angry|irritable|happy|fluctuating"][textarea memo="other" default="" rows="1"]
Affect- [checkbox value="sad|tearful|anxious|flattened|restricted|irritable|happy|full range"][textarea memo="other" default="" rows="1"]
Speech: [select value="Normal rate and rhythm, not pressured|pressured|paucity"][textarea memo="other" default="" rows="1"]
Thought process: [select value="logical, linear, age appropriate|circumstantial|"][textarea memo="other" default="" rows="1"]
Associations: [select value="intact|loose|tangential|"][textarea memo="other" default="" rows="1"]
Thought Content: [select value="no evidence of delusions, |"][select value="no evidence of response to internal stimuli, |"][select value="no suicidal ideation or intentions, |"][select value="no homicidal ideation or intentions|"][textarea memo="other" default="" rows="1"]
Orientation: [select value="Oriented to person, place, and time|unable to assess due to cognitive impairment|"][textarea memo="other" default="" rows="1"]
Attention and Concentration: [select value="Adequate attention and concentration based on answers to interview questions|unable to assess due to cognitive impairment|impaired attention and concentration as evidenced by |"][textarea memo="other" default="" rows="1"]
Memory: [select value="Recent and remote memories both intact based on Pt's answers to interview questions|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Language: [select value="No evidence of aphasia |"][select value="|, able to name objects|[select value="|, able to repeat phrases"][select value="|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Judgment and Insight:
Judgment- [select value="fair|good|poor|impulsive"][textarea memo="other" default="" rows="1"]
Insight- [select value="fair|good|poor"][textarea memo="other" default="" rows="1"]
Fund of Knowledge: Based on the answers to interview questions, Pt's intelligence is judged to be [select value="average|above average|below average|unable to assess due to cognitive impairment"][textarea memo="other" default="" rows="1"]
Time spent:[checkbox value="38-52 min"][comment memo="45 min 90836"][checkbox value="53-67 min"][comment memo="60 min 90838"]
Focus of psychotherapy:[checkbox value="interpersonal conflict|emotional experience related to diagnosis|identification of coping mechanisms|grief counseling"][textarea memo="other" default="" rows="1"]
Modality:[checkbox value="insight oriented|supportive|behavioral modification"]
Diagnosis:[checkbox value="Major depressive disorder|recurrent|single episode|mild|moderate|severe|Generalized anxiety disorder|PTSD|acute|chronic|Adjustment Disorder|with depressed mood|with anxiety|with depressed mood and anxiety"]
[textarea rows="2"]
Pt is currently displaying [select value="symptoms of|well managed|moderately managed|poorly managed"] [checkbox value="depression|anxiety|sleep disturbance|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|alcohol dependence|opiate dependence|autism spectrum disorder"][textarea memo="other" default="" rows="1"] which is [select value="likely caused by|likely exacerbated by|likely the result of"] [checkbox value="their cancer diagnosis|their cancer treatment|their unmanaged depressive disorder|their unmanaged anxiety disorder|their unmanaged bipolar disorder|interpersonal/family conflict|current psychopharmaceutical intervention|current psychotherapy|current psychosocial support systems"][textarea memo="other" default="" rows="1"]. Pt would benefit from [checkbox value="continued psychopharmaceutical intervention|adjustments to current psychopharmaceutical intervention|continuation of current psychotherapy|engaging in grief therapy|engaging in CBT|engaging in family therapy|enhanced psychosocial supports|increasing personal time and self-care"][textarea memo="other" rows="1"]. Prognosis is [select value="good|fair|poor"] considering the Pt [select value="remains adherent to|actively engages in|is not currently responding to"] medication/therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success include: "][checkbox value="current apprehension to engage in psychopharmaceutical intervention|current apprehension to engage in structured psychotherapy|current emotional distress of recent cancer diagnosis|limited social supports|dysfunctional interpersonal relationships"][textarea memo="barriers" rows="1"]. [checkbox value="Pt strength for success include: "][checkbox value="expression of willingness to engage in treatment recommendations|positive social supports|are well connected with outpatient supports|history of actively engaging in mental-health treatment"][textarea memo="strengths" rows="1"]. [textarea rows="2"]
[checkbox value="-Pt will report score on PHQ-9 of 8 or less within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Pt will report score on GAD-7 of 8 or less within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Pt will reduce nicotine intake by 50% within one month: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Pt will experience 6+ hours of uninterrupted sleep per night within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"][checkbox value="
-Pt will report impact of cognitive impairment as mild/resolved within 3 months: Initiated "][textarea rows="1"][checkbox value=" not currently meeting| currently meeting|worsening|improving|stable"]
General Complete History
Date of Service: [text name="field_name" default="sample text"]
 Demographics
Age: [text name="field_name" default="sample text"]y.o
Gender: [select name="field_name" value="Male|Female|Other"]
Race: [select name="field_name" value="African American|Caucasian|Hispanic|Asian|Other"]
SUBJECTIVE:
Chief complaint (CC): [text name="field_name" default="sample text"]
History of present illness (HPI):
 is a [text name="field_name" default="sample text"] seen for [text name="field_name" default="sample text"].  has a history of [text name="field_name" default="sample text"]
[textarea name="variable_1" default=" reports\nPatient is using\nPatient has used\nBefore illness:\nImpact of illness on lifestyle:"]
[textarea name="variable_1" default="General Health and Strength:\nSignificant Childhood Illnesses:\nMajor Adult Illnesses or Chronic Illnesses:"]
Limitation of abilities:
--Hearing: [checklist name="field_name" value="Unilateral|Bilateral|sensory loss|neural loss|sensorineural loss|wears hearing aid"]
--Vision: [checklist name="field_name" value="legally blind|glasses|contacts"]
--Speech:[text name="field_name" default="sample text"]
--Gait:[checklist name="field_name" value="frequent falls|cane|tripod cane|quad-cane|walker|wheeled walker|frequent falls|rollator|wheelchair|electric wheelchair"]
Social history
--Place of birth/childhood: [text name="field_name" default="sample text"]
--Socioeconomic status: [text name="field_name" default="sample text"]
--Education level: [text name="field_name" default="sample text"]
--Places visited: [text name="field_name" default="sample text"]
--Places lived: [text name="field_name" default="sample text"]
--Diet: [text name="field_name" default="sample text"]
--Exercise: [text name="field_name" default="sample text"]
--Home Conditions: [text name="field_name" default="sample text"]
--Occupations: [text name="field_name" default="sample text"]
--Environment: [text name="field_name" default="sample text"]
--Military Record: [text name="field_name" default="sample text"]
--Religious or Cultural Preferences: [text name="field_name" default="sample text"]
--Access to Care: [text name="field_name" default="sample text"]
--Smoking History: [text name="field_name" default="sample text"]
--Alcohol Use: [text name="field_name" default="sample text"]
--Illicit Drugs: [text name="field_name" default="sample text"]
--Sexual History: [text name="field_name" default="sample text"]
--Breast Self-Exams: [text name="field_name" default="sample text"]
--------------------------------------------------------------------------------------------
Family history:
--Mother: [text name="field_name" default="sample text"]
--Father: [text name="field_name" default="sample text"]
--Siblings: [text name="field_name" default="sample text"]
--Children: [text name="field_name" default="sample text"]
--Grandparents:[text name="field_name" default="sample text"]
--Aunts or Uncles: [text name="field_name" default="sample text"]
--Cousins: [text name="field_name" default="sample text"]
----------------------------------------------------
Risks:
[textarea name="field_name" default="sample text"]
----------------------------------------------
Review of Systems:
--Constitutional: c/o [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"] [text name="field_name" default="sample text"]. Denies: [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"].
--Head: c/o [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"].
--Eyes: c/o [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].
--Ears: c/o [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent
infections"] [text name="field_name" default="sample text"]. [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent
infections"].
--Nose: c/o [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"].
--Mouth and Throat: c/o [checklist name="field_name" value="hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"].
--Neck: c/o [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"].
--Cardiac: c/o [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].
--Vascular: c/o [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities"].
--Respiratory: c/o [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].
--Gastrointestinal: c/o [checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] [text name="field_name" default="sample text"]. Denies[checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"]
--Endocrine: c/o [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|
mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|
mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"].
--Hematological/Lymphatic: c/o [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].
--Genitourinary: c/o [checklist name="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]
Reproductive (female): c/o [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]. Gravida [text name="field_name" default="sample text"] Para [text name="field_name" default="sample text"] Abortus [text name="field_name" default="sample text"]. LMP: [text name="field_name" default="sample text"].
Reproductive (male): c/o [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"].
--Musculoskeletal: c/o [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].
--Neurological: c/o [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"].
--Psychiatric: c/o [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges
|irritability|tension|suicidal thoughts|homicidal thoughts"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges
|irritability|tension|suicidal thoughts|homicidal thoughts"]
--Breasts: c/o [checklist name="field_name" value="breast pain/soreness|discharge|lumps"]
[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="breast pain/soreness|discharge|lumps"]
==============================================
--General Appearance:
LOC:[checklist name="field_name" value="Alert|Awake|Aware|Asleep|Responds to Verbal Stimulus|Responds to Pain|Unresponsive |Lethargic|Unconscious"]
Nutrition: [checklist name="field_name" value="well-nourished|cachexic"]
Distress: [checklist name="field_name" value="observable pain cues|appears in no acute distress"]
Nurtition: Weight: [text name="field_name" default="sample text"] BMI: [text name="field_name" default="sample text"] Weight changes: [text name="field_name" default="sample text"]
--Last Pap Smear: [text name="field_name" default="sample text"]
Actual diagnosis:
[text name="field_name" default="sample text"]
DDx:
--On this visit:
Procedures:
[textarea name="field_name" default="sample text"],
Purpose of Procedure:
Consent was [select name="field_name" value="obtained verbally|obtained written|not obtained"]
--Medications Discontinued:
--Medications Given:
--Medication Refills:
--Labs Ordered:
--Diagnostics Ordered:
--Referrals:
--Follow-up:
--Education Given:
 is a [text memo="age" size="2"]-year-old,[checkbox value=" white| African-American| Hispanic| Asian|"] [checkbox value="female|male|transgender female|transgender male|gender non-binary individual"] [select name="variable_9" value="with no past psychiatric history,|with history of |"]
[checkbox value="depression|MDD|situational depression|anxiety|GAD|panic attacks|mood disorder|bipolar disorder|somatic symptoms|somatic symptom disorder|ADHD|PTSD|dementia|dementia with behavioral disturbances|OCD|psychosis|substance abuse|personality disorder|maladaptive personality traits|recurrent suicidal ideation|suicide attempt|schizoaffective disorder, bipolar type|schizoaffective disorder|schizophrenia|psychosis|unknown mental health diagnosis|severe persistent mental illness|psychiatric hospitalization|noncompliance with psychiatric medications/treatment"][textarea memo=" " rows="5"]
 [select value="initially presented to emergency department|initially presented to outside emergency department|was transferred here from outside facility"][select value=" alone| with family| with significant other| via EMS | already sedated and intubated| by police||"] [select value=" |complaining of |for complaints of | due to report of | for higher level of care due to "][text memo="PRESENTING PROBLEM" size="20"]. [select name="variable_13" value="Per ED records,|Per outside records, |Per chart,|At time of admission,|Upon transfer and admission here,||"][select value=" reported |family reported |friend reported|EMS reported |staff at the facility reported|it was reported |outside records indicated |police reported| was"][textarea memo="history of presenting complaints" rows="3"] [select name="variable_13" value="In ED, work-up showed|At outside hospital,| Initial work-up showed|| "][textarea name="variable_1" default=""] [select name="variable_14" value="No UDS results noted. |UDS at outside hospital reportedly|UDS was"] [checkbox name="variable_1" value="+amphetam/metham|+barbituates|+benzos|+cocaine|+opiates|+phencyclidine|+THC|+methadone screen"]. [select name="Druglevel1" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."] [select name="Druglevel2" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."] [select name="Druglevel3" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."] [select name="Druglevel4" value="||Acetominophen level less than 10.0 mcg/mL . |Acetominophen level high at X mcg/mL .|Salicylate level less than 10.0 mg/dl .|Salicylate level elevated at X mg/dl .|Lithium level therapeutic at X .|Lithium level low at X, not trough.|Lithium level low at X .|Lithium level high at X.|Depakote level high at X.|Depakote level low at X, not trough.|Depakote level low at X ."]
Psychiatry consultation requested for[select value=" evaluation and management of | due to reports of |"][text memo="presenting problem" size="20"].  seen for psychiatric consultation [select name="variable_18" value="in hospital room on medical floor.|in ICU.|"] [select name="variable_20" value=" is poor informant due to symptomatic presentation.| is poor informant due to current somnolence.| is poor informant due to cognitive impairments.| is considered reliable historian."][select name="variable_17" value="Sitter is at bedside and steps out for interview.|Sitter is at bedside.|"] [select name="variable_15" value="No family/friends present.|Spouse is at bedside |Family is at bedside|Friend is at bedside|Caregiver is at bedside"][select name="variable_16" value="|and provides collateral history.|and provides majority of history.|but steps out for interview at  request.|but steps out for interview."]
[select value="Per report from ,|Per family report,|Per review of chart,|Per report from care giver, |Reportedly,|Apparently,"][select value="  was in usual state of mental health until| had no history of mental health concerns until | has been having problems with|"][textarea memo="Mental health history" rows="5"]. [checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"] [var name=""]'s depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].[textarea memo="Additional Depression information" rows="5"][/conditional][conditional field="anxiety" condition="(anxiety).is('')"]  anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"][select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]
[select value="Per ,|Per family,|Per record,|"][text size="20"][select value=" they have been |  has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]
[var name="name"] has a pattern of [checkbox name=addtype value="inattention and hyperactivity/impulsivity|inattention|hyperactivity/impulsivity"] that interferes with functioning. [/conditional][conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('inattention')"] Inattention manifests as [checkbox memo="At least 6 for ADHD" value="poor attention to details or careless mistakes in work or activities|difficulty sustaining attention|not seeming to listen when spoken to directly|not following through on instructions or failing to finish tasks|having difficulty organizing tasks and activities|avoiding tasks that require sustained mental effort|frequently losing things necessary for tasks|often easily distracted by extraneous stimuli|forgetfulness in daily activities"].[/conditional] [conditional field="addtype" condition="(addtype).is('inattention and hyperactivity/impulsivity')||(addtype).is('hyperactivity/impulsivity')"] [var name="name"]'s hyperactivity/impulsivity presents as [checkbox memo="six or more for ADHD" value="frequent fidgeting or squirming|often leaving seat when remaining seated is expected|frequently restless|difficulty engaging in leisure activities quietly|often seeming to be on the go or difficult to keep up with|excessive talking|blurting out answers before a question has been completed|difficulty waiting for their turn|interrupting or intruding on others"][/conditional][conditional field="adhd" condition="(adhd).is('')"]
These symptoms have been present since [text memo="before 12yo" size="20"], and are recognized in multiple settings including [text memo="2 or more" size="20"]. [textarea rows="3"][/conditional]
[conditional field="sleep" condition="(sleep).is('')"]Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include | is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional][conditional field="sleep" condition="(sleep).isNot('')"]Sleep is reported to be generally good. [/conditional][conditional field="depression" condition="(depression).isNot('')"] denies any marked issues with depression. [/conditional][conditional field="anxiety" condition="(anxiety).isNot('')"] denies any significant issues with anxiety. [/conditional][conditional field="mood" condition="(mood).isNot('')"] denies a history of mania, excessive mood lability, grandiosity, or uncharacteristic risk taking behavior. [/conditional]
[select value="Current psychiatric medications include: | is unable to recall current psychiatric medications|Unable to cover current psychiatric medications with  due to symptomatic presentation|"][textarea rows="4"]. [select value=" denies current outpatient psychiatric follow-up| currently receiving outpatient psychiatric services through| currently followed for outpatient psychiatric medication with|"][textarea rows="1"]. [select value=" denies currently receiving individual counseling/therapy| currently engaging in individual counseling with |"][textarea rows="1"]. [select value=" denies current suicidal ideation or thoughts of self harm| reports currently experiencing | denies current suicidal ideation but endorses thoughts of"][textarea rows="1"]. [checkbox value="With good eye contact and without hesitation,  is able to contract for safety.| is not able to contract for safety."][textarea rows="1"] [select value=" denies having access to guns| reports guns at home| reports having access to guns"][textarea rows="1"].
REVIEW OF SYSTEMS
[comment memo="Use freetext to explain {+}s if needed"]
[checkbox memo="Constitutional" name="Constitutional" value=""][conditional field="Constitutional" condition="(Constitutional).is('')"]Constitutional: [checkbox name="Constitutional1" value="fever"][/conditional][conditional field="Constitutional1" condition="(Constitutional1).is('fever')"][select value="(-)|{+}"], [/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional2" value="chills"][/conditional][conditional field="Constitutional2" condition="(Constitutional2).is('chills')"][select value="(-)|{+}"], [/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional3" value="malaise"][/conditional][conditional field="Constitutional3" condition="(Constitutional3).is('malaise')"][select value="(-)|{+}"], [/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional4" value="unexplained wt gain/loss"][/conditional][conditional field="Constitutional4" condition="(Constitutional4).is('unexplained wt gain/loss')"][select value="(-)|{+}"][/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"][checkbox name="Constitutional5" memo="freetext" memo_size="small" value=""][/conditional][conditional field="Constitutional5" condition="(Constitutional5).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="Constitutional" condition="(Constitutional).is('')"]
[/conditional][checkbox memo="Musculoskeletal" name="Musculoskeletal" value=""][conditional field="Musculoskeletal" condition="(Musculoskeletal).is('')"]Musculoskeletal:[checkbox name="Musculoskeletal1" value=" muscle pain"][/conditional][conditional field="Musculoskeletal1" condition="(Musculoskeletal1).is(' muscle pain')"][select value="(-)|{+}"], [/conditional][conditional field="Musculoskeletal" condition="(Musculoskeletal).is('')"][checkbox name="Musculoskeletal2" value=" back pain"][/conditional][conditional field="Musculoskeletal2" condition="(Musculoskeletal2).is(' back pain')"][select value="(-)|{+}"], [/conditional][conditional field="Musculoskeletal" condition="(Musculoskeletal).is('')"][checkbox name="Musculoskeletal3" value="joint pain/swelling"][/conditional][conditional field="Musculoskeletal3" condition="(Musculoskeletal3).is('joint pain/swelling')"][select value="(-)|{+}"] [/conditional][conditional field="Musculoskeletal" condition="(Musculoskeletal).is('')"][checkbox name="Musculoskeletal4" memo="freetext" memo_size="small" value=""][/conditional][conditional field="Musculoskeletal4" condition="(Musculoskeletal4).is('')"]
--[textarea memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"][/conditional][conditional field="Musculoskeletal" condition="(Musculoskeletal).is('')"]
Psychiatric:
The pt is a [text memo="age" size="2"]-year-old,[checkbox value=" white|African-American|Hispanic|Asian|"] [checkbox value="female|male|transgender female|transgender male|gender non-binary individual"] with past psychiatric history of
[checkbox value="depression|MDD|situational depression|anxiety|GAD|panic attacks|mood disorder|bipolar disorder|somatic symptoms|somatic symptom disorder|ADHD|PTSD|dementia|dementia with behavioral disturbances|OCD|psychosis|substance abuse|personality disorder|maladaotive personality traits|recurrent suicidal ideation|suicide attempt|schizoaffective disorder, bipolar type|schizoaffective disorder|schizophrenia|psychosis|unknown mental health diagnosis|severe persistent mental illness|psychiatric hospitalization|noncompliance with psychiatric medications/treatment"] [textarea memo=" " rows="5"].
pt [select value="initially presented to emergency department|initially presented to outside emergency department "][select value=" alone| with family| with significant other| via EMS | via transfer from outside facility| by police||"] [select value=" for complaints of | due to report of | for higher level of care due to "][text memo="PRESENTING PROBLEM" size="20"]. Per ED records, [select value="the pt reported |family reported |friend reported|EMS reported |staff at the facility reported|it was reported |outside records indicated |police reported|"][textarea memo="history of presenting complaints" rows="3"]. In ED, work-up showed [textarea name="variable_1" default="sample text"].
[checkbox name="depression" memo="depression" value=""][checkbox name="anxiety" memo="anxiety" value=""][checkbox name="sleep" memo="sleep" value=""][checkbox name="mood" memo="mood" value=""][checkbox name="ptsd" memo="ptsd" value=""][checkbox name="adhd" memo="adhd" value=""][checkbox name="autism" memo="autism" value=""][conditional field="depression" condition="(depression).is('')"] [var name="name"]'s depression is characterized as [checkbox value="little interest or pleasure in doing things|hopelessness|helplessness|sleeping too much|difficulty getting to sleep|difficulty staying asleep|feeling tired or having little energy|poor appetite|overeating|feelings of inadequacy|irritability|poor concentration|psychomotor retardation|psychomotor agitation|suicidal ideation"]. [select value="Depressive symptoms are present most of the day, nearly every day|Depressive symptoms are mostly present |"][text size="20"][select value=", are exacerbated by |"][text size="20][select value=", are improved by |"][text size="20]. [select value="Depressive symptoms impact|"][select value=" social/work functioning by | "][textarea rows="1"].[textarea memo="Additional Depression information" rows="5"][/conditional][conditional field="anxiety" condition="(anxiety).is('')"] The pt's anxiety generally presents as [checkbox value="feeling nervous or on edge|worry|difficulty relaxing|feeling restless|difficulty getting to sleep|difficulty staying asleep|irritability|poor appetite|overeating"][text size="20]. [select value="Anxiety is present |"][select value="in the context of multiple different situations/events such as |primarily in social situations such as | "][textarea rows="1"]. [select value="Anxiety usually last for approximately |Anxiety is present most of the time on most days"][text size="20"][select value=", is brought on by |"][text size="20][select value=", is relieved by |"][text size="20]. [textarea memo="Additional Anxiety information" rows="5"][/conditional][conditional field="mood" condition="(mood).is('')"][select value=" Mood instability has been an issue since |"][text size="20"]. [select value="Disordered mood can present as |"][checkbox value="euphoria|excessive energy|excessive self-confidence|insomnia|irritability|agitation|racing thoughts|impulsive behavior|risk taking behavior|paranoia|delusions of grandeur|auditory hallucinations|visual hallucinations|depression|apathy|hopelessness|helplessness|suicidal thoughts|no motivation|hypersomnia"]. [select value="Mood lability is exacerbated by |There are no identified precipitating factors to mood lability|"][textarea rows="1"]. [textarea memo="additional information of mood lability" rows="4"][/conditional][conditional field="autism" condition="(autism).is('')"]
[select value="Per pt,|Per family,|Per record,|"][text size="20"][select value=" they have been | pt has been |"][select value="diagnosed|undiagnosed|"][text size="20"][select value=" autism spectrum disorder "][textarea memo="details of diagnosis/symptom timeframe" rows="4"]. [var name="name"]'s symptoms present as persistent difficulty, in multiple contexts, with social communication and interaction including: [checkbox value="abnormal or failed back and forth conversation|failure to initiate or respond to social interactions|reduced sharing of interests/emotions|limited emotional affect|limited/incongruent nonverbal communication|difficulty with developing/maintaining/understanding relationships|difficulty sharing imaginative play|limited or absent interest in peers"]. They have demonstrated restricted/repetitive patterns of behavior, interests, or activities including: [checkbox value="repetitive motor movements|repetitive speech|infexible adherence to routines|ritualized patterns of verbal or nonverbal behavior|significant difficulty with transitions|rigid thinking patterns|highly restricted and fixated interests|hyper-reactivity to sensory input|hyporeactivity to some sensory input"]. Presentation is [select value="without|with"] intellectual impairment, and [select value="without|with"] language impairment. [textarea rows="4"][/conditional][conditional field="adhd" condition="(adhd).is('')"]
[conditional field="sleep" condition="(sleep).is('')"]Sleep is reported to be generally [select name="sleepq" value="poor |fair |good.|erratic |inconsistent |excessive|"][select value="with difficulty initiating sleep and staying asleep due to |with difficulty initiating sleep due to |with difficulty maintaining sleep due to |"][textarea rows="2"]. They estimate getting approximately [text size="4"] hours of [select value="broken |solid |"]sleep per night. [select value="Disturbed sleep has been an issue for |Disturbed sleep is a new issue within the last |"][textarea rows="1"]. [select value="There has been no workup for Sleep Apnea|There was a past workup for sleep apnea which indicated |"][textarea rows="1"]. [select value="Current attempts at improving sleep include |The pt is currently attempting no interventions to improve sleep|Current quality of sleep is dependent on |"][textarea rows="2"]. [select value="Past unsuccessful attempts at improving sleep include |There have been no past attempts at improving sleep|"][textarea rows="2"].[/conditional][conditional field="sleep" condition="(sleep).isNot('')"]Sleep is reported to be generally good. [/conditional][conditional field="depression" condition="(depression).isNot('')"]denies any marked issues with depression. [/conditional][conditional field="anxiety" condition="(anxiety).isNot('')"]denies any significant issues with anxiety. [/conditional][conditional field="mood" condition="(mood).isNot('')"]denies a history of mania, excessive mood lability, grandiosity, or uncharacteristic risk taking behavior. [/conditional]
[select value="Current psychiatric medications include: |pt is unable to recall current psychiatric medications|Unable to cover current psychiatric medications with pt due to symptomatic presentation|"][textarea rows="4"]. [select value="They are not currently receiving individual counseling/therapy|They are currently engaging in individual counseling with |"][textarea rows="1"]. [select value="denies current suicidal ideation or thoughts of self harm|They report positive for |denies suicidal ideation but state having thoughts of being better off dead"][textarea rows="1"]. [checkbox value="They are able to contract for safety.|denies being able to contract for safety."][textarea rows="1"] [select value="denies having access to guns|They report positive for having guns in the home |"][textarea rows="1"]. [checkbox value=" Explained that we ask this question because guns in the home increase the risk of suicide, homicide and accidental death, Provided education about the importance of keeping guns locked and separated from ammunition. Explained that should this provider feel that pt is unsafe to self or others, provider and pt will work together to develop a safe place to keep weapons to decrease risk of impulsive suicide or homicide."]
PSYCHIATRIC HISTORY:
[select value="Previous psychiatric medication trials include but may not be limited to: |The pt has no history of taking psychiatric medications|We were unable to cover previous psychiatric medication trials due to symptomatic presentation|The pt is unable to recall past psychiatric medication trials|"][textarea rows="1"]. [select value="There is no history of psychiatric hospitalizations|They have been psychiatrically hospitalized |"][textarea rows="2"]. [select value="Previous psychiatric/counseling services includes |They have no history of psychiatric/counseling|History of psychotherapy/counseling was not addressed due to symptomatic presentation|"][textarea rows="2"]. [select value="denies history of diagnosis/treatment for an eating disorder|They report positive for a history of diagnosis/treatment for an eating disorder including |Unable to assess for history of diagnosis/treatment of an eating disorder due to symptomatic presentation|History of diagnosis/treatment of an eating disorder was not assessed in this encounter|"][textarea rows="1"].[select value="They have no history of thoughts of self-harm|History of thoughts of self harm include |"][textarea rows="2"]. [select value="They have no history of attempting to hurt themself|History of self-harm includes |Unable to obtain history of self-harm due to symptomatic presentation"][textarea rows="2"]. [select value="They have no history of head injuries or traumatic brain injuries|They have a past history of traumatic brain injuries resulting from |They have an underlying cognitive impairment from |"][textarea rows="2"]. [select value="There is no history of trauma|They report having a history of trauma but did not want to elaborate|They report past traumatic experiences to include |Trauma history was not covered due to symptomatic presentation|"][textarea rows="2"]. [select value="They report positive for tobacco use consuming approximately |They report a past history of tobacco but quit approximately |denies any tobacco use|"][textarea rows="1"]. [select value="They report positive for alcohol use consuming approximately |They report a history abuse quitting approximately |denies any alcohol use|"][textarea rows="2"]. [select value="denies a history of recreational substance use|They report utilizing cannabis approximately |They have a history of opiate use disorder |They report utilizing opiates recreationally in the form of |Substance use history was not covered due to symptomatic presentation|"][textarea rows="4"].
SOCIAL HISTORY:
Living situation: [select value="lives with significant other|lives with family|lives alone|is homeless|lives with parents|lives with children|lives with roommate|lives in a grouphome|is currently residing in SNF|lives in nursing facility|lives in an assistant living facility|is homeless, currently staying at shelter|is homeless, currently living transiently "][text size="20"] in [text memo="residing location" size="20"]
[var name="name"] identifies [checkbox value="having no one as|significant other|extended family|children|friends|church members"][textarea rows="1"] social-support network. They have [select value="0|1|2|3|4|5|6|7|"][textarea rows="1"] children. Their level of education is [select value="highschool|an undergraduate degree in |a graduate degree in |some highschool|some college|currently in grade school|currently in highschool|currently in college studying |currently in graduate school studying |"][textarea rows="1"]. They are [select value="currently on disability due to their mental health condition|currently on disability due to their medical condition|currently employed |currently retired from |"][textarea rows="1"]. Financially they [select value="have no immediate concerns|are burdened by healthcare costs|have concerns related to supporting their family|"][textarea rows="1"]. Their source of income is primarily [select value="disability|social security|unemployment|current employment|family support|"][textarea rows="1"]. They have [select value="no current housing concerns|a currently unstable housing situation related to |"][textarea rows="1"]. [select value="Spirituality was not addressed this visit|Spirituality is identified as |"][select value="|Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"][textarea rows="1"]. Sexual orientation [select value="was not addressed this visit|is identified as |"][select value="|heterosexual|homosexual|bisexual|pansexual|asexual"][textarea rows="1"]. [select value="They have no military history|Military history includes |Military history was not addressed this visit|"][textarea rows="1"]. [select value="They have no current legal concerns|Legal concerns include |Legal concerns were not addressed due to symptomatic presentation"][textarea rows="1"].
FAMILY PSYCHIATRIC HISTORY
[select value="denies knowledge of a family history of mental illness|Family history of mental health problems is positive for |Unable to cover family history of psychiatric issues due to symptomatic presentation"][textarea rows="4"]. [select value="There is no known history of suicides or self-harm in the pt's family|Family history of suicides/self-harm includes |Unable to cover family history of suicides/self-harm due to symptomatic presentation|"][textarea rows="2"]. [select value="There is no known family history of substance use issues|Family history of substance use is positive for |Unable to cover family history of substance use issues due to symptomatic presentation|"][textarea rows="4"].
[text name="variable_1" default="Constitutional: "][select name="variable_1" value="White female, |White male,|African-American female,|African American male,|Hispanic female, |Hispanic male,|Asian female, |Asian male, |Black male,|Black female,| "][checkbox name="variable_1" value="in no apparent distress|looks given age|looks older than given age|looks younger than given age|well developed|chronically ill appearing|good attention to hygiene|breathing comfortably|cachectic|disheveled|comfortable|cooperative|distressed|frail|malnourished|moderately overweight|moderately uncomfortable|morbidly obese|non-toxic|overweight|petite|pleasant|pregnant|sleepy|somewhat tired|thin|uncomfortable appearing|undernourished|with a pleasant expression|with anasarca"].
[text name="variable_2" default="Musculoskeltal: "][checkbox name="variable_2" value="erect posture with smooth, coordinated gait, stable station|muscle strength for upper/lower extremities intact bilaterally with appropriate muscle tone and symmetry|full range of motion for all joints without crepitation or instability appreciated|bilateral muscle weakness in upper/lower extremities appreciated as a result of medical status|bilateral limitation of motion and stiffness appreciated as a result of current medical condition"].
[text name="variable_3" default="pt Related Activities: "][checkbox name="variable_3" value="reviewed available records in Cerner|obtained history from collateral person|obtained and reviewed outside records|reviewed TN CSMD profile"].[comment memo="Text that will not show up in output"][comment memo="Text that will not show up in output"][comment memo="Text that will not show up in output"]
Follow-up visit for [checkbox name="variable_1" value="suicidal ideation|suicide attempt|depression|anxiety|mood disorder|bipolar disorder|somatic symptoms|agitation|delirium|dementia|dementia with behavioral disturbances|AMS|psychosis|substance abuse|substance withdrawal|pt on 6404|pt on 6401|re-evaluation of capacity|re-evaluation of need for geripsych|re-evaluation of need for emergency psychiatric hospitalization"].
[checkbox name="variable_2" value="First time seeing pt, case discussed with handing off provider."]
Chart/labs/imaging/assessments reviewed. Interval events discussed with staff. [select name="variable_2" value="In the past 24 hours|In the past 48 hours|Since admission"], pt [select name="variable_3" value="has|has not"] required psychiatric PRNs [textarea name="variable_2" default="-"], [select name="variable_4" value="has|has not"] required restraints[textarea name="variable_3" default=""], [select name="variable_5" value="has|has not"] endorsed suicidal ideation [textarea name="variable_4" default=""], and [select name="variable_6" value="has|has not"] required involvement of security [textarea name="variable_5" default=""].
[select name="variable_1" value="Per nursing|Per tech| Per staff|Per report from primary team |Per case management|Per attending|Reportedly|Per review of interval notes"],[textarea name="variable_1" default=" today the pt has been appropriate, cooperative with care and treatment, eating/drinking OK, not agitated and not appearing to respond to internal stimuli."]
[checkbox name="variable_3" value="pt seen for follow-up in hospital room on medical floor|pt seen for follow-up on unit| Dr. Sharpe also in attendance| RN present during interview|sitter at bedside, but steps out for interview|sitter at bedside during interview|security present during interview"]. Family/friends [select name="variable_7" value="are at bedside|are not currently at bedside but were reportedly here earlier|are not at bedside|are not at beside and have reportedly not been involved during admission"].
Constitutional/General:
Confirms: [checkbox name="symp_Constitutional_confirms" value=" fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
Denies: [checkbox name="symp_Constitutional_denies" value=" fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
Head:
Confirms: [checkbox name="symp_head_confirms" value="headaches|dizziness|syncope|sinus pain|LOC"]
Denies: [checkbox name="symp_head_denies" value="headaches|dizziness|syncope|sinus pain|LOC"]
Eyes:
Confirms: [checkbox name="symp_eyes_confirms" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"]
Denies: [checkbox name="symp_eyes_denies" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"]
Ears:
Confirms: [checkbox name="symp_ears_confirms" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"]
Denies: [checkbox name="symp_ears_denies" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"]
Nose,Mouth, and Throat:
Confirms: [checkbox name="symp_nose_confirms" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"]
Denies: [checkbox name="symp_nose_denies" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"]
Confirms: [checkbox name="symp_mouth_confirms" value="hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"]
Denies: [checkbox name="symp_mouth_denies" value="hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"]
Skin:
Confirms: [checkbox name="symp_skin_confirms" value="diagnosed skin conditions|new lesions|rashes|discoloration|dryness|hair changes"]
Denies: [checkbox name="symp_skin_denies" value="diagnosed skin conditions|new lesions|rashes|discoloration|dryness|hair changes"]
Neck:
Confirms: [checkbox name="symp_neck_confirms" value="neck pain|stiffness|edema"]
Denies: [checkbox name="symp_neck_denies" value="neck pain|stiffness|edema"]
Cardiac:
Confirms: [checkbox name="symp_cardiac_confirms" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"]
Denies: [checkbox name="symp_cardiac_denies" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].
Confirms: [checkbox name="symp_cardiac2_confirms" value="claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"]
Denies: [checkbox name="symp_cardiac2_denies" value="claudication|color changes in extremities|parathesias|coldness in extremities"]
Respiratory:
Confirms: [checkbox name="symp_resp_confirms" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"]
Denies: [checkbox name="symp_resp_denies" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"]
Gastrointestinal:
Confirms: [checkbox name="symp_gastro_confirms" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"]
Denies: [checkbox name="symp_gastro_denies" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"]
Endocrine:
Confirms: [checkbox name="symp_endo_confirms" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"]
Denies: [checkbox name="symp_endo_denies" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"]
Hematological/Lymphatic:
Confirms: [checkbox name="symp_hema_confirms" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"]
Denies: [checkbox name="symp_hema_denies" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"]
Genitourinary:
Confirms: [checkbox name="symp_gastro_confirms" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]
Denies: [checkbox name="symp_gastro_denies" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]
Reproductive (female):
Confirms: [checkbox name="symp_repro_f_confirms" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]
Denies: [checkbox name="symp_repro_f_denies" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]
Gravida (been pregnant):
Para (Full Term):
Premature Births:
Abortus (Non Viable pregnancies):
Last Mestral Period:
Pregnant: [select name="symp_female1_prego" value="No=1|Maybe=2|Yes=3"]
Reproductive (male):
Confirms: [checkbox name="symp_repro_m_confirms" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain|hernias"]
Denies: [checkbox name="symp_repro_m_denies" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain|hernias"]
Musculoskeletal:
Confirms: [checkbox name="symp_musk_confirms" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"]
Denies: [checkbox name="symp_musk_denies" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"]
Integument:
Confirms: [checkbox name="symp_inte_confirms" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"]
Denies: [checkbox name="symp_inte_denies" value="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"]
Neurological:
Confirms: [checkbox name="symp_neuro_confirms" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"]
Denies: [checkbox name="symp_neuro_denies" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"]
Confirms: [checkbox name="symp_psych_confirms" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"]
Denies: [checkbox name="symp_psych_denies" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"]
Social:
Confirms: [checkbox name="symp_social_confirms" value="change in home|relationships|employment|substance use|exercise|exposure"]
Denies: [checkbox name="symp_social_denies" value="change in home|relationships|employment|substance use|exercise|exposure"]
Function:
Confirms: [checkbox name="symp_funct_confirms" value="change in activities of daily living|memory|capacity"]
Denies: [checkbox name="symp_funct_denies" value="change in activities of daily living|memory|capacity"]
Breasts:
Confirms: [checkbox name="symp_breast_confirms" value="breast pain/soreness|discharge|lumps"]
Denies: [checkbox name="symp_breast_denies" value="breast pain/soreness|discharge|lumps"]
Summary: This is the documentation system for diagnosis of psychiatric illness.
Axis I: Psychiatric Illness
[textarea default="Such as Major Depression, Anxiety Disorder, Obsessive Compulsive Disorder, or Bipolar Disorder"]
Axis II: Chronic Developmental Disorders and Personality Disorders
[textarea default="Developmental disorders includes Autism and Mental Retardation; Personality disorders include Paranoid, Antisocial, and Borderline Personality Disorders, among others"]
Axis III: Physical Conditions
[textarea default="Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness"]
Axis IV: Psychosocial Stressors
[textarea default="Events in a person's life, such as death of a loved one, starting a new job, college, unemployment, and marriage"]
Axis V: Global Assessment of Functioning (GAF)
Current GAF
[select name="Q1" value="91-100: Higher level functioning in broad range of activities with good and control of typical life stressors|81-90: Other than mild psychiatric symptoms for common triggers, good level of functioning|71-80: Mild psychiatric symptoms with triggers and mild impact on functioning|61-70: Mild psychiatric symptoms with impact on functioning, but overall functioning is good and relationships are maintained|51-60: Moderate psychiatric symptoms with moderate impact on functioning|41-50: Serious symptoms and impaired functioning|31-40: Impaired reality and major Impairment|21-30: Delusions, hallucinations, or serious Impairment|11-20: Danger to self or others|1-10: Persistent danger to self or others"]
Highest GAF in the last year
[select name="Q2" value="91-100: Higher level functioning in broad range of activities with good and control of typical life stressors|81-90: Other than mild psychiatric symptoms for common triggers, good level of functioning|71-80: Mild psychiatric symptoms with triggers and mild impact on functioning|61-70: Mild psychiatric symptoms with impact on functioning, but overall functioning is good and relationships are maintained|51-60: Moderate psychiatric symptoms with moderate impact on functioning|41-50: Serious symptoms and impaired functioning|31-40: Impaired reality and major Impairment|21-30: Delusions, hallucinations, or serious Impairment|11-20: Danger to self or others|1-10: Persistent danger to self or others"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
[link url="//psychiatryonline.org/" memo="#1"] Diagnostic and Statistical Manual of Mental Disorders
[/conditional]