Physician Review

Client Name:

Today's Date:

8/23/2015

Appointment Start Time:

CMH Case Manager:

Case:
Duration:

1. Current Psychiatric Symptoms/Concerns

Mood:

Elevated

Depressed

Irritable

Delusions: Denies

Self Injurious Behavior: Denies

Liability of Affect: Stable

Disorganized Thoughts: Denies

Impulsivity: Denies

Sleep: No Change

Thought Broadcasting/Insertion: Denies

Flashbacks

Appetite: No Change

Ideas of Reference:Denies

Obsessions

Interest in Activities: No Change

Grandiosity: Denies

Compulsions/Rituals: Denies

Energy: No Change

Anxiety: Denies

Suicidality: Denies

Concentration: No Change

Excessive Worry: Denies

Homicidality: Denies

Racing Thoughts: Denies

Phobias

Substance Abuse/Use: Denies

Hallucinations: Denies

ADL's

EtOH/ Cigs/ THC

2. History

3. Medication Issues Since Last Visit:

Y
N Takes medicine as prescribed?
Y

Is the medicine helpful?

Any physical problems after taking medication?

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

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

Y
N
Vitals: Wt:
New Medical Problems since last visit:

PCP

Last Labs:

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

Psychotropics:

Other Meds:

BP:

Pulse:

CONSUMER NAME

CASE NUMBER

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

Appearance:
Attitude:

Well Groomed

Appropriate Dress

Bizarre

Disheveled

Cooperative

Personable

Suspicious

Guarded

Belligerent/
Hostile

Hyperactive

Agitated

Tremors/Tics

Disorganized

Dyskenisia

Behavior

Labile

Constricted

Flat

Uncooperative
Calm

Motor Activity:

Hypoactive
Inappropriate

Broad

Appropriate

Equable

Mood:

Euthymic

Depressed

Anxious

Euphoric

Irritable

Speech:

Normal

Impoverished

Pressured

Slurred

Incoherent

Thought Processes:

Clear/Coherent

Tangential

Flight of Ideas

Loose Assoc.

Circumstantial

Hallucinations:

No Evidence

Auditory

Visual

Olfactory

Tactile

Delusions:

No Evidence

Persecutory

Being Controlled

Grandiose

Somatic

Suicidality:

No Evidence

Present

No Plan

Plan

Homicidality:

No Evidence

Present

No Plan

Plan

Affect:

Thought content:

Intact
Judgment:
Insight Regarding the Presence of the Disorder:

Age Appropriate

Impaired:

Absent

MILD

MODERATE

Poor

Fair

SEVERE
Good

Level of
Sensorium:

Cognition:
grossly intact

Consciousness:

Alert

Drowsy

Stupor

Orientation Intact:

Person

Place

Time

Situation

Attention:

Normal

Impaired:

Unimpaired

Immediate Recall

Recent

Remote

Intact

Impaired

Memory Problems:
Executive Function:

Medication Consent Obtained

AIMS Evaluation Performed

Risks/Side Effects/Benefits Discussed

Evaluation of Level of Pain Performed

Assessment:

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

Are you satisfied with the services that you are receiving?

Psychiatrist or Physician

Yes

No

Date