VIRTUAL VISIT Check In Form Morrison Clinic

ADHD TREATMENT
Are you currently prescribed a medication for treatment of ADHD?*
----ADHD----

Improvements should be based on what you think your symptoms would be in your current circumstances if you were not medicated for ADHD.
-----If you had to guess, how many hours of your day is your current medication regimen actively in your system and helping symptoms of ADHD? *
---- ADHD INATTENTIVE AND HYPERACTIVE SYMPTOM RESPONSE TO CURRENT TREATMENT----
-----When your medication is in your system do you notice improvements in your energy, motivation, task completion, and attention to detail?*
-----Do you think your improvements in energy, motivation, and task completion are ideal considering your current task load, stressors, and life circumstances?*
-----Do you think your improvements in cognitive disorganization, restlessness, and being fidgety are ideal considering your current task load, stressors, and life circumstances?*
-----Is there anything in regards to inattentive or hyperactive symptoms that you think I need to know or that you want to discuss today? *
----ADHD ANXIETY SYMPTOM RESPONSE TO CURRENT TREATMENT----
-----When your medication is in your system do you notice improvements in your ability to process thoughts and feelings without being as overwhelmed, reactive, and emotionally impulsive? When you are stressed, is it easier to pause and be mindful and do you better recognize thought distortions? *
-----Do you think your improvements in anxiety from ADHD are ideal considering your current task load, stressors, and life circumstances?*
-----Is there anything in regards to anxiety from ADHD that you think I need to know or that you want to discuss today? *
----ADHD MOOD SYMPTOM RESPONSE TO CURRENT TREATMENT----
-----When your medication is in your system do you notice improvements in your ability to regulate emotions and tap into logic and reasoning when you are upset? Are you less reactive to frustration, more patient, and not as easily frustrated? *
-----Do you think your improvements in the mood symptoms of ADHD are ideal considering your current task load, stressors, and life circumstances?*
-----Is there anything in regards to the mood symptoms of ADHD that you think I need to know or that you want to discuss today? *

Untreated ADHD
Do you think your energy, motivation, and task completion are well managed considering your current task load, stressors, and life circumstances?*
Do you think your cognitive disorganization, restlessness, and being fidgety are well managed considering your current task load, stressors, and life circumstances?*
Do you think anxiety that is secondary to cognitive disorganization, cognitive restlessness, and physical restlessness is well managed considering your current task load, stressors, and life circumstances? *
Do you think mood symptoms that are secondary to emotional impulsivity, cognitive disorganization, and impatience a well are managed considering your current task load, stressors, and life circumstances? *
Do you think the ADHD symptoms of difficulties with listening, completing tasks, communicating clearly, impulsivity, and regulating emotions are well managed and not having a negative impact on relationships with friends, family, and co-workers? *

MAJOR DEPRESSIVE DISORDER SYMPTOM RESPONSE TO CURRENT TREATMENT

SYMPTOMS OF DEPRESSION AND MOOD DISORDERS INCLUDE: frequent feelings of depression or sadness, cognitive fatigue and slowing, low motivation for activities that normally lead to enjoyment, decreased activity level due to feeling sad or emotionally depleted, lack of interest in activities and people that normally lead to feelings of enjoyment, being bothered by thoughts that you would be better off dead or of hurting yourself in some way seeing or hearing things other people don't see or hear, delusional beliefs or paranoia that other people don’t believe
-Are any of the above symptoms problematic or is there anything in regards to MDD that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.*
-Do you think your improvements in your depression/mood disorder and the above symptoms are well managed considering your current stressors and life circumstances?*
Mood Assessment Blurb

GENERALIZED ANXIETY DISORDER SYMPTOM RESPONSE TO CURRENT TREATMENT

SYMPTOMS OF Generalized anxiety include: anxiety that leads to becoming easily annoyed or irritable , not being able to stop or control worry, feeling anxious, nervous, or on edge, anxiety that makes it hard to concentrate and is distracting, headaches from tension in neck and shoulders, anxiety that is draining and leads to fatigue
--Are any of the above symptoms problematic or is there anything in regards to GAD that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.*
--Do you think your improvements in your generalized anxiety and the above symptoms are well managed considering your current stressors and life circumstances? *
Anxiety Assessment Blurb
Cognitive Assessment Blurb
Mental Status Exam

----Panic Disorder Symptom Response to Current Treatment----

Symptoms of panic disorder include severe and recurrent panic attacks that interfere with daily function. The panic attack is brief and discrete period of intense fear, anxiety, or discomfort with distressing physical symptoms of anxiety that occur out of the blue and are NOT due to being upset, stressed out, or worried. Within 10 minutes the anxiety has peaked and the feelings of panic do not last an extended period of time but are so intense that you avoid situations known to trigger the attacks. Panics can be triggered by situations in which escape might be difficult, not readily available, or would be embarassing.
-----Are any of the above symptoms problematic or is there anything in regards to panic disorder that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.*
-----Do you think your improvements in your panic disorder and the above symptoms are well managed considering your current stressors and life circumstances? *

---- Social Anxiety Disorder: SMSAD----

Instructions: The following questions ask about thoughts, feelings, and behaviors that you may have had about social situations. Usual social situations include: public speaking, speaking in meetings, attending social events or parties, introducing yourself to others, having conversations, giving and receiving compliments, making requests of others, and eating and writing in public.
Social phobia is rooted in a fear of embarassment. Are your symptoms of social anxiety due to a fear of embarassment?*
During the PAST 7 DAYS, I have felt moments of sudden terror, fear, or fright in social situations*
During the PAST 7 DAYS, I have felt anxious, worried, or nervous about social situations*
During the PAST 7 DAYS, I have had thoughts of being rejected, humiliated, embarrassed, ridiculed, or offending others*
During the PAST 7 DAYS, I have felt a racing heart, sweaty, trouble breathing, faint, or shaky in social situations*
During the PAST 7 DAYS, I have felt tense muscles, felt on edge or restless, or had trouble relaxing in social situations*
During the PAST 7 DAYS, I have avoided, or did not approach or enter, social situations*
During the PAST 7 DAYS, I have left social situations early or participated only minimally (e.g., said little, avoided eye contact)*
During the PAST 7 DAYS, I have spent a lot of time preparing what to say or how to act in social situations*
During the PAST 7 DAYS, I have distracted myself to avoid thinking about social situations *
During the PAST 7 DAYS, I have needed help to cope with social situations(e.g., alcohol or medications, superstitious objects)*
Please add up the answers for your social anxiety test and type the number below. *
Based on the following score ranges, what is the severity of your social anxiety? *
---- SOCIAL PHOBIA SYMPTOM RESPONSE TO CURRENT TREATMENT----
----------What percentage of social activities will you avoid going to?*
-----When you do go to a social activity, what percentage of the time will you have intense and bothersome symptoms of anxiety? What symptoms do you experience?*
-----Do you think your improvements in your social anxiety are ideal considering your current stressors and life circumstances?*
-----Is there anything in regards to social anxiety that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.*
How difficult have these anxiety symptoms made it for you to do your work, take care of things at home, or get along with other people?*

OCD: BOCS

Please respond according to the situation during the last seven days (including today).
Approximately, how much of your time is occupied by obsessive‐compulsive problems?*
On the average, what is the longest amount of consecutive waking hours per day that you are completely free of obsessive‐compulsive problems?*
How much do your obsessive‐compulsive problems interfere with your everyday life, work or school, or social functioning?*
How much distress do your obsessive‐compulsive problems cause you?*
How much control do you have over your obsessive‐compulsive problems? How successful are you in stopping or diverting them? If you rarely try to resist, please think about those rare occasions on which you did try.*
Have you been avoiding doing anything, going anyplace or being with anyone in order to avoid your obsessive compulsive problems? *
Please add up the answers for your OCD test and type the number below. *
Based on the following score ranges, what is the severity of your OCD.*
---- OCD SYMPTOM RESPONSE TO CURRENT TREATMENT----
-What % of improvement have you had in your obsessions?*
What % of improvement have you had in your compulsions?*
What % of improvement have you had in avoiding activities that trigger your OCD?*
Is there anything in regards to OCD that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.*
Which of the following best describes your obsessive compulsive traits*
How difficult have these anxiety symptoms made it for you to do your work, take care of things at home, or get along with other people?*

PTSD:PCL-C

The next questions are about problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are: “not at all”, “a little bit”, “moderately”, “quite a bit”, or “extremely”.
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past? *
Repeated, disturbing dreams of a stressful experience from the past? *
Suddenly acting or feeling as if a stressful experience from the past were happening again(as if you were reliving it)? *
Feeling very upset when something reminded you of a stressful experience from the past? *
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past?*
Avoiding thinking or talking about a stressful experience from the past or avoiding having feelings related to it? *
Avoided activities or situations because they reminded you of a stressful experience from the past?*
Having trouble remembering important parts of a stressful experience from the past? *
Loss of interest in activities that you used to enjoy? *
Feeling distant or cut off from other people?*
Feeling emotionally numb or being unable to have loving feelings for those close to you? *
Feeling as if your future somehow will be cut short? *
Having trouble falling or staying asleep? *
Feeling irritable or having angry outbursts? *
How difficult have these anxiety symptoms made it for you to do your work, take care of things at home, or get along with other people?*
Difficulty concentrating? *
Being “superalert” or watchful or on guard? *
Feeling jumpy or easily startled? *
Please add up the answers for your PTSD test and type the number below. *
Based on the following score ranges, what is the severity of your PTSD? *
-Is there anything in regards to PTSD that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.*
-Do you think your improvements in your PTSD are ideal considering your current stressors and life circumstances?*
How difficult have these anxiety symptoms made it for you to do your work, take care of things at home, or get along with other people?*

PMDD SYMPTOM RESPONSE TO CURRENT TREATMENT----

SYMPTOMS OF PMDD INCLUDE: fatigue, lack of interest, and decreased motivation the week prior to menstrual cycle, emotional sensitivity or sadness the week prior to menstrual cycle, worsening in concentration the week prior to menstrual cycle
Please note problematic symptoms or anything in regards to PMDD that you think I need to know or you would like to discuss today? *
Please note the average severity of your PMDD symptoms over the last 30 days. *
-----Do you think your improvements in your PMDD and the above symptoms are well managed considering your current stressors and life circumstances? *
How difficult have these PMDD symptoms made it for you to do your work, take care of things at home, or get along with other people?*

Binge Eating Disorder SYMPTOM RESPONSE TO CURRENT TREATMENT----

SYMPTOMS OF BINGE EATING INCLUDE:binging, inability to stop or control binge and during binge eats even when not hungry, feeling embarrassed by binges, feeling guilty or disgusted with self after binge, or binges occurring when unable to sit thru a negative emotion.
-----Do you think your improvements in your binge eating and the above symptoms are well managed considering your current stressors and life circumstances? *
-----How many times a week do you binge eat?*
-----Is there anything in regards to binge eating that you think I need to know or that you want to discuss today? *
How difficult have these binge eating symptoms made it for you to do your work, take care of things at home, or get along with other people?*

Young Mania Rating Scale

The YMRS is typically administered by a third-party clinician, but it is provided here, in a slightly reworded form, as a self-assessment. This may not be as accurate when self-administered, as people suffering from mania are often unable to properly assess relevant outward symptoms.There are 11 groups of statements in this questionnaire, read each group of statements carefully. Specify one of the choices that best describes the way you have been feeling for the past week by clicking the dot next to the appropriate statement.
1. Elevated Mood*
2. Increased motor activity or energy*
3. Sexual Interest*
4. Sleep*
5. Irritability*
6. Speech: Rate and Amount*
7. Language-thought Disorder*
8. Content of thoughts*
9. Disruptive: Aggressive Behavior*
10. Appearance*
11. Insight*
Please add up the answers for your YMRS test and type the number below. *
Based on the following score ranges, what is the severity of your mania? *
Is there anything in regards to mania that you think I need to know or that you want to discuss today? Please list symptoms you think we need to discuss.
Do you think your improvements in your bipolar disorder and the above symptoms are well managed considering your current stressors and life circumstances?
How difficult have these mania symptoms made it for you to do your work, take care of things at home, or get along with other people?Type a question*

Suicidal Ideation and Plan Assessment
Do you have access to a gun?*
When you have thought about killing yourself did you think that was something you would actually do?*
Frequency*
Duration*
Controllability *
Deterrents*
Reasons for Ideation*
What is your plan for ending your life?*
When will you act on this plan?*
Where will you be when you act on this plan?*
How will you execute this plan?*
Have you done anything to get ready to kill yourself like giving things away,writing a goodbye note, getting things you need to kill yourself?*
Can you contract for safety and promise that if you do not feel safe and are afraid you will end your life that you will call someone for help before acting on the thoughts? *
WAIT TIME: While we do our very best to start your session at the assigned start time, please keep in mind that the average wait time to see a medical provider is 18 minutes. This typically occurs in instances where the clinician is running behind due to unforseen medical needs of patients scheduled before your time slot.

Your time is valuable and we thank you in advance for your patience if the clinician is running behind.
If you can contract for safety, who would you call? What is their number?*

FORM SUBMISSION: AFTER YOU click submit you will be automatically directed to our virtual lobby check in.
Should be Empty:

This lobby check in form is for both new and established patients and needs to be filled out prior to EVERY appointment.

Vital Signs

Heart Rate

Tele-Psychiatry Additional Information

Insurance information for prior authorization processing during appointment.

Triage form

---- SLEEP DISORDER RESPONSE TO CURRENT TREATMENT---

CURRENT MEDICAL ILLNESSES:

PSYCHOTHERAPY TREATMENT PLAN

Psychotherapy compliance

Psychotherapy Non Compliance

PSYCHOTHERAPY

ADHD TREATMENT

----ADHD----

---- ADHD INATTENTIVE AND HYPERACTIVE SYMPTOM RESPONSE TO CURRENT TREATMENT----

----ADHD ANXIETY SYMPTOM RESPONSE TO CURRENT TREATMENT----

----ADHD MOOD SYMPTOM RESPONSE TO CURRENT TREATMENT----

Untreated ADHD

MAJOR DEPRESSIVE DISORDER SYMPTOM RESPONSE TO CURRENT TREATMENT

GENERALIZED ANXIETY DISORDER SYMPTOM RESPONSE TO CURRENT TREATMENT

----Panic Disorder Symptom Response to Current Treatment----

---- Social Anxiety Disorder: SMSAD----

---- SOCIAL PHOBIA SYMPTOM RESPONSE TO CURRENT TREATMENT----

OCD: BOCS

---- OCD SYMPTOM RESPONSE TO CURRENT TREATMENT----

PTSD:PCL-C

PMDD SYMPTOM RESPONSE TO CURRENT TREATMENT----

Binge Eating Disorder SYMPTOM RESPONSE TO CURRENT TREATMENT----

Young Mania Rating Scale

Suicidal Ideation and Plan Assessment

FORM SUBMISSION: AFTER YOU click submit you will be automatically directed to our virtual lobby check in.