Physician ReviewClient Name: Today's Date: 4/21/2023 Case:

CMH Case Manager: Appointment Start Time: Duration:

1. Current Psychiatric Symptoms/Concerns

Mood: Elevated Depressed Irritable

Flashbacks

Obsessions

Phobias

↓ ADL's EtOH/ Cigs/ THC

2. History

3. Medication Issues Since Last Visit:

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

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

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

New Medical Problems since last visit: Y N Vitals: Wt: # BP: Pulse:

PCP Last Labs:

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

Psychotropics: Other Meds:

Delusions: Denies Self Injurious Behavior: Denies

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

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

↑ ↓ Appetite: No Change Ideas of Reference:Denies

↑ ↓ 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 Substance Abuse/Use: Denies

Hallucinations: Denies

CONSUMER NAME 0 CASE NUMBER 0

Appearance: Well Groomed Appropriate Dress Bizarre Disheveled

Attitude: Cooperative Personable Suspicious Guarded

Uncooperative

Motor Activity: Calm Hyperactive Agitated Tremors/Tics Disorganized

Hypoactive Dyskenisia Behavior

Affect: Inappropriate Broad Labile Constricted Flat

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

Thought content:

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

Judgment: Intact Age Appropriate Impaired: MILD MODERATE SEVERE

Absent Poor Fair Good

Sensorium:

Level of

Consciousness: Alert Drowsy Stupor

Orientation Intact: Person Place Time Situation

Attention: Normal Impaired:

Memory Problems: Unimpaired Immediate Recall Recent Remote

Executive Function: Intact Impaired

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

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

Belligerent/ Hostile

Insight Regarding the Presence of the Disorder:

Cognition: grossly intact

Labs:

Meds: NO MED CHANGE

RTC 12 Weeks

ANURADHA CHALLA, M.D. 4/21/2023

Psychiatrist or Physician Date