Anxiety/Depression Symptoms

‍‍HISTORY: 
‍‍﻿ mood for ‍﻿ ﻿
‍‍Stressors: ‍﻿ ‍﻿﻿
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‍‍Severity: ‍﻿, ‍﻿ significant distress
‍‍Negative impact on: ‍﻿﻿
‍‍Reaction to stressors is  than would normally be expected
‍‍Treatments tried: ‍﻿, ‍﻿﻿
‍‍Past psychiatric history: ‍﻿﻿
‍‍Family psychiatric history: ‍﻿﻿
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‍‍Social history:
‍‍Smoking: ‍﻿, ‍﻿ pack-years
‍‍Alcohol: ‍﻿, ‍﻿ drinks per ‍﻿﻿
‍‍Recreational drugs: ‍﻿ ‍﻿, ‍﻿﻿
‍‍Caffeine: ‍﻿ per day
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‍‍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
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‍‍ASSESSMENT: 
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‍‍DDx: ‍﻿﻿
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‍‍PLAN: 
‍‍- Psychoeducation about mental condition
‍‍- Stress management techniques
‍‍- Regular exercise
‍‍- Sleep hygiene
‍‍- Avoidance of alcohol and drugs
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‍‍- 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