Today's Date:

Appointment Start Time:

3. Medication Issues Since Last Visit:

Y N Y N

Y N Y N

4. Physical Symptoms, Illnesses, or Hospitalizations since last visit:

Y N Wt: # BP:

PCP

5. Current Medications (include those from other physicians):

CMH Case Manager:

1. Current Psychiatric Symptoms/Concerns

Mood: Elevated Depressed Irritable Delusions: Denies Self Injurious Behavior: Denies

Physician ReviewClient Name: 8/23/2015 Case:

Duration:

↑ ↓ Appetite: No Change Ideas of Reference:Denies Obsessions

↑ ↓ Interest in Activities: No Change Grandiosity: Denies Compulsions/Rituals: Denies

Liability of Affect: Stable Disorganized Thoughts: Denies Impulsivity: Denies

↑ ↓ Sleep: No Change Thought Broadcasting/Insertion: Denies Flashbacks

Racing Thoughts: Denies Phobias Substance Abuse/Use: Denies

Hallucinations: Denies ↓ ADL's EtOH/ Cigs/ THC

↑ ↓ Energy: No Change Anxiety: Denies Suicidality: Denies

↑ ↓ Concentration: No Change Excessive Worry: Denies Homicidality: Denies

New Medical Problems since last visit:

Last Labs:

2. History

Takes medicine as prescribed? Any physical problems after taking medication?

Is the medicine helpful? Are there times of the day that are better or worse?

Vitals: Pulse:

Psychotropics: Other Meds:

CONSUMER NAME CASE NUMBER

6. Mental Status Examination (check all that apply):

Appearance:

Mood:

Speech:

Thought Processes:

Thought content:

Hallucinations:

Delusions:

Suicidality:

Homicidality:

Judgment: Impaired: MILD MODERATE SEVERE

Level of

Medication Consent Obtained Y N AIMS Evaluation Performed Y N

Risks/Side Effects/Benefits Discussed Y N Evaluation of Level of Pain Performed Y N

Assessment:

GAF =

Plan (Meds/Labs, Orders, Follow-up Needs):

Are you satisfied with the services that you are receiving? Yes No

Psychiatrist or Physician

0 0

Well Groomed Appropriate Dress Bizarre Disheveled

Hypoactive Dyskenisia

Attitude:Cooperative Personable Suspicious Guarded

Belligerent/ Hostile

Uncooperative

Euthymic Depressed Anxious Euphoric Irritable

Behavior

Affect:Inappropriate Broad Labile Constricted Flat

Appropriate Equable

Motor Activity:Calm Hyperactive Agitated Tremors/Tics Disorganized

Normal Impoverished Pressured Slurred Incoherent

Clear/Coherent Tangential Flight of Ideas Loose Assoc. Circumstantial

No Evidence Auditory Visual Olfactory Tactile

No Evidence Persecutory Being Controlled Grandiose Somatic

No Evidence Present No Plan Plan

No Evidence Present No Plan Plan

Executive Function: Intact Impaired

Intact Age Appropriate

Insight Regarding the Presence of the Disorder: Absent Poor Fair

Unimpaired

Good

Sensorium: Consciousness: Alert Drowsy Stupor

Orientation Intact: Person Place

Immediate Recall Recent Remote

Time Situation

Date

Meds:

RTC

Labs:

Cognition: grossly intact

Attention: Normal Impaired:

Memory Problems: