Mental health progress consultation

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
- mental health progress consultation

Current symptoms: 
[-] Low/depressed mood 
[-] Anxiety 
[-] Mood swings 
[-] Reduced ability to cope with daily problems or stress 
[-] Irritability 
[-] Lowered energy or motivation 
[-] Elevated energy/arousal 
[-] Fears, worries, or feelings of guilt 
[-] Changes in eating habits or appetite 
[-] Weight loss/gain 
[-] Libido changes 
[-] Confused thinking or reduced ability to concentrate 
[-] Detachment from reality (delusions), paranoia or hallucinations 
[-] Trouble understanding and relating to situations and to people

Sleep: 
  Usual bedtime: 
  Hours of sleep: 
[-] initial insomnia 
[-] early morning wakening 
[-] daytime sleepiness

Suicide/self-harm: 
[-] ideation/thoughts
[-] intent/plan

Harm to others: 
[-] ideation/thoughts
[-] intent/plan

Patient's assessment of progress since last review: 
(Things that are: [+] better, [~] unchanged, [-] worse; [!] new problem)
[+] 
[~] 
[-] 
[!]

Patient's feedback on therapy sessions: 
  Sessions completed since last review:

Patient's feedback:

Communication received from therapy provider/s: 
-

Current psychotropic medication review: 
  Agent: 
  Date started: 
  Effectiveness: 
  Side effects:

Agent: 
  Date started: 
  Effectiveness: 
  Side effects:

[Clinical observations]

Mental State Observations: (abnormalities)
[-] Appearance
[-] Behaviour
[-] Motor activity
[-] Speech
[-] Mood (patient [-] subjective)
[-] Affect (examiner [-] observations)
[-] Thought processes
[-] Thought content
[-] Perceptions
[-] Cognition
[-] Orientation
[-] Attention/concentration
[-] Memory
[-] Abstract reasoning
[-] Insight
[-] Judgement
[-] Numeric skills
[-] Construction and spatial skills
[-] Abstract thinking

Mental health assessment tool (e.g. DASS 21, K10, PHQ-9):

ASSESSMENT
Main symptom areas:
[-] neurological and psychological development 
[-] cognition 
[-] attention/hyperactivity 
[-] thought/psychosis 
[-] low/depressed mood 
[-] anxiety 
[-] bipolar features 
[-] fear/phobia 
[-] obsession/compulsion 
[-] stress/trauma 
[-] feeding/eating 
[-] personality/behaviour 
[-] substance use 
[-] bodily distress/somatisation 
[-] sexual function 
[-] gender

Diagnosis/es (if relevant):
1.

Clinician's assessment of progress since last review: 
(Things that are: [+] better, [~] unchanged, [-] worse; [!] new problem)
[+] 
[~] 
[-] 
[!]

MANAGEMENT PLAN
Modification of treatment plan if required: 
-

Changes to prescribed medication: 
-

Checking, reinforcing and expanding education: 
-

Actions to be taken by the patient: 
-

Role of carer/support person(s): 
-

New referrals:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260120]

Mental health progress consultation

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