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Mental Health
Deprescribing
Home
About
Mental Health
Deprescribing
Mental Health Consultation
Mental Health
Mental Health Appointment Type
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New
Follow-up
Review
Consult Type
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Telephone
Video
Face to Face
Mood
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N/A
Poor
Worsening
Stable
Improving
Good
Anxiety
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N/A
Poor
Worsening
Stable
Improving
Good
Cognitive functioning / Concentration
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N/A
Poor
Worsening
Stable
Improving
Good
Psychomotor activity
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N/A
Poor
Worsening
Stable
Improving
Good
Speech / Thought form
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N/A
Bad
Worsening
Stable
Improving
Good
Delusional beliefs present?
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N/A
No
Yes
Describe
Hallucinations present?
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N/A
No
Yes
Hallucination Type
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N/A
Auditory
Visual
Auditory & Visual
Other
Describe
Suicidal ideation / Self-harm thoughts
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N/A
None
Passive
Active
Recent Attempt
Describe
Risk to others
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N/A
None
Low
Moderate
High
Describe
Insight into illness
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N/A
Poor
Worsening
Stable
Improving
Good
Mental Health Additional Notes
Physical Health
Sleep Quality
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N/A
Bad
Worsening
Stable
Improving
Good
Further Information
Appetite / Weight changes
N/A
Losing Weight
Decreased Appetite
Stable
Increased Appetite
Gaining Weight
Energy Levels
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N/A
Low
Worsening
Stable
Improving
High
Physical health problems impacting mental health?
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N/A
No
Yes
Describe
Medication adherence
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N/A
Poor
Worsening
Stable
Improving
Good
Medication side effects present?
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N/A
No
Yes
Describe
Substance Abuse (alcohol, drugs)
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N/A
None
Mild
Moderate
Severe
Describe
Physical Health Additional Notes
Social Health
Social / Occupational Functioning
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N/A
Low
Worsening
Stable
Improving
Good
Daily living skills / Self-care
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N/A
Poor
Worsening
Stable
Improving
Good
Current Living Situation Safe?
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N/A
Yes
No
Describe
Support network present (family/friends)?
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N/A
Yes
No
Who?
Employment / Education status
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N/A
Employed
Unemployed
Retired
Student
Financial Stressors
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N/A
Yes
No
Describe
Cultural / spiritual needs impacting care?
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N/A
Yes
No
Describe
Appearance
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N/A
Well-kempt
Unkempt
Eye Contact
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N/A
Good
Bad
Other (specify)
Describe
Calm or Anxious Demeanour
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N/A
Calm
Anxious
Describe
Social Health Additional Notes
Plan
Medication
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N/A
Started
Maintained
Increased
Decreased
Stopped
Further Details
Psychological Support
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N/A
Recommended
Referred
Increased
Currently Supported
Previously Supported
Further Details
Follow Up
General Notes
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