Adjustment Disorder follow-up
Age: years old
Gender:
HISTORY:
Returns for a follow-up
Last visit was ago
Progress since last visit:
Current stressors: , , , , ,
Updates on symptoms:
, , a plan, intent to act
Medications:
, , , , ,
Change at last visit: , ,
Use of rescue sedative:
Adherence:
Psychotherapy: , ,
Other interventions tried: , , , , ,
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Labs: TSH: , Hb:
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 , disoriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
,
DDx: depressive disorder, anxiety disorders, acute stress disorder, post-traumatic stress disorder, personality disorders, bipolar disorder, situational crisis, substance-induced mood disorder, mood disorder due to a medical condition, normal bereavement
PLAN:
Treatments:
- Psychoeducation about adjustment disorder
- Stress management techniques
- Relaxation techniques
- Regular exercise
- Healthy diet
- Sleep hygiene
- Avoidance of alcohol and drugs
-
- Cognitive behavioral therapy
Further care:
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts
HISTORY: EXAM: Mental Status: ASSESSMENT: PLAN: