HISTORY:
mood for
Stressors:
Severity: , significant distress
Negative impact on:
Reaction to stressors is than would normally be expected
Treatments tried: ,
Past psychiatric history:
Family psychiatric history:
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Caffeine: per day
EXAM:
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , attention , memory
Judgment:
Insight: into condition
ASSESSMENT:
DDx:
PLAN:
- Psychoeducation about mental condition
- Stress management techniques
- Regular exercise
- Sleep hygiene
- Avoidance of alcohol and drugs
-
-
-
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Leave of absence from work for
- Follow-up in with
- Return before if condition worsen or if new symptoms develop such as suicidal thoughts