mine

**History of Present Illness (HPI)**

{Patient Name: text} is a {Age: number} year-old {Gender: dropdown: Male, Female, Non-binary, Other} with a history of {Previous Diagnoses: check: Major Depressive Disorder, Generalized Anxiety Disorder, Bipolar I Disorder, Bipolar II Disorder, Schizophrenia, Schizoaffective Disorder, PTSD, OCD, ADHD, Borderline Personality Disorder, Substance Use Disorder, Autism Spectrum Disorder, Adjustment Disorder, Insomnia, Other: text}. The patient presents today with {Chief Complaint: text} for {Duration: text}.

The current episode began {Onset: dropdown: suddenly, gradually, insidiously} and has been characterized by {Primary Symptoms: check: depressed mood, anxiety, irritability, elevated mood, mood swings, anhedonia, fatigue, worthlessness, guilt, hopelessness, concentration difficulties, indecisiveness, psychomotor agitation, psychomotor retardation, panic attacks, obsessions, compulsions, hallucinations, delusions, suicidal ideation, homicidal ideation, substance craving, insomnia, hypersomnia, appetite increase, appetite decrease, weight gain, weight loss, decreased libido, increased libido, other: text}. These symptoms are described as {Severity: dropdown: mild, moderate, severe} and have {Progression: dropdown: improved, worsened, remained unchanged} since onset.

The patient reports that the symptoms {Frequency: dropdown: occur constantly, occur intermittently, are episodic}, typically {Timing: dropdown: in the morning, in the afternoon, in the evening, throughout the day, at night, after specific triggers: text} and last for {Duration: text}. The patient identifies {Triggers: text} as potential triggers.

Associated symptoms include {Associated Symptoms: check: nausea, headaches, dizziness, palpitations, chest pain, shortness of breath, muscle tension, tremors, GI distress, other: text}, while the patient denies {Pertinent Negatives: check: suicidal ideation, homicidal ideation, hallucinations, delusions, substance use, medication non-compliance, recent trauma, other: text}.

The patient has a history of {Psychiatric Treatment History: check: previous hospitalizations, outpatient therapy, medication management, psychotherapy, ECT, TMS, substance use treatment, other: text}, and is currently taking {Current Medications: textarea} at the following dosages: {Medication Dosages: textarea}. The patient reports {Adherence: dropdown: full adherence, partial adherence, non-adherence} to the prescribed treatment and has experienced {Side Effects: text}.

The patient’s functional status has been {Functional Impact: dropdown: severely impaired, moderately impaired, mildly impaired, not impaired}, particularly affecting {Impact Areas: check: work, school, social relationships, family life, daily activities, self-care, other: text}. The patient’s insight into their condition is {Insight: dropdown: good, fair, poor} and their motivation for treatment is {Motivation: dropdown: strong, moderate, weak}.

Collateral information was obtained from {Collateral Sources: text}, which {Discrepancies: dropdown: corroborates, contradicts, provides additional details to} the patient’s account. 

The patient’s current risk level is assessed as {Risk Assessment: dropdown: low, moderate, high} based on their reported symptoms and history.

**Plan:**

The treatment plan includes {Treatment Plan: textarea}. Follow-up is scheduled for {Follow-up Interval: dropdown: 1 week, 2 weeks, 1 month, other: text}.

---

**Template Use:**

To use this template:
1. Copy the text above into SOAPnote.org.
2. Replace placeholder text and select appropriate options for each patient.
3. The template will generate a structured, readable HPI that can be used directly in clinical documentation.