| RPT |
.|.|TIDES Care Initial Assessment||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
present:| <*Answer_4198*>|13. Risk Assessment/Management comments:| <*Answer_4199*>|14. Diagnosis of depression in past?| <*Answer_4200*>|15. Prior treatment for depression:|
<*Answer_4201*>|16. Previous trials of antidepressants:| <*Answer_4202*>|17. Previous periods of psychotherapy:| <*Answer_4203*>|18. Dysthymia symptoms: (In the past two years, have you felt
depressed or sad most days, even if you felt okay sometimes?)| <*Answer_4204*>|18.1 Which symptoms have you had?| <*Answer_5101*>|19. Functioning during the past two years:|
<*Answer_4205*>|20. Comments on history of depression:| <*Answer_4206*>|21. Patient currently on antidepressant?| <*Answer_4207*>|22. Patient taking antidepressant as directed?|
<*Answer_4208*>|23. Last filled Rx:| <*Answer_4209*>|24. Any side-effects from antidepressant?| <*Answer_4210*>|25. Intensity of side-effects:| <*Answer_4211*>|26. Side-effect(s) from
antidepressant (Check all that apply):| <*Answer_4212*>|27. Comments on medication compliance and side-effects| <*Answer_4213*>|28. Describe sleep:| <*Answer_4214*>|29. Hours of sleep:|
<*Answer_4215*>|30. Describe appetite:| <*Answer_4216*>|31. Weight change:| <*Answer_4217*>|32. Symptoms in last month (Which of these symptoms has bothered you in the last month?)|
<*Answer_4218*>|33. Comments on symptoms:| <*Answer_4219*>|34. Medical co-morbidities (Check all that apply):| <*Answer_4220*>|35. Impact on physical health:| <*Answer_4221*>|36. New
medications in last two months (Check all that apply):| <*Answer_4222*>|37. Other medications herbs, or drugs (Check all that apply):| <*Answer_4223*>|38. Recent loss of family or friend?|
<*Answer_4224*>|39. History of alcohol abuse?| <*Answer_4225*>|40. Has patient used alcohol in past year?| <*Answer_4226*>|41. Frequency of alcohol use:| <*Answer_4227*>|42. Drinks per day:|
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||Today's date:| <*Answer_4534*>|1. PHQ-9: Declined or could not do.| <*Answer_4187*>|2. Initial PHQ-9 score:|
<*Answer_4228*>|43. Number of days in a month when patient has five or more drinks:| <*Answer_4230*>|44. Does patient want alcohol treatment?| <*Answer_4229*>|45. Does patient have alcohol
abuse in Problem List?| <*Answer_4231*>|46. Patient reports significant drug abuse?| <*Answer_4232*>|47. Does patient have drug abuse in Problem List?| <*Answer_4233*>|48. In past month, has
patient felt anxious, frightened or had panic attack(s)?| <*Answer_4234*>|49. Does the patient want a referral for anxiety/panic symptoms?| <*Answer_4235*>|50. Anxiety/panic in Problem List?|
<*Answer_4236*>|51. PTSD factors (Check all that apply):| <*Answer_4287*>|52. Diagnosed with PTSD?| <*Answer_5102*>|53. PTSD in active Problem list?| <*Answer_5103*>|54. Referral for PTSD
treatment:| <*Answer_4238*>|55. Bipolar diagnosis (Check all that apply):| <*Answer_4239*>|56. Presence of hallucinations or delusions?| <*Answer_4240*>|57. Comments regarding co-morbidity:|
<*Answer_4241*>|58. Empolyment:| <*Answer_4242*>|59. Is patient involved in volunteer work?| <*Answer_4243*>|60. Does patient have hobbies or activities?| <*Answer_4244*>|61. Marital
status:| <*Answer_4245*>|62. Living situation:| <*Answer_4246*>|63. Patient is able to care for self:| <*Answer_4247*>|64. Children (Check all that apply):| <*Answer_4248*>|65.
Social/Family support:| <*Answer_4249*>|66. Support system:| <*Answer_4250*>|67. Is there a specific support person?| <*Answer_4251*>|68. Supportive persons (relationship, not names):|
<*Answer_4281*>|69. Patient stressors (Check all that apply):| <*Answer_4252*>|70. Comments on functioning/support/stressors| <*Answer_4253*>|71. Service era (Check all that apply):|
<*Answer_4285*>|72. Was the patient asked about his/her concerns or questions?| <*Answer_5104*>|73. Patient's questions and concerns:| <*Answer_4255*>|74. Patient's treatment preferences:|
<*Answer_4188*>|3.1 Little interest or pleasure:| <*Answer_4535*>|3.2. Feeling down, depressed or hopeless:| <*Answer_4536*>|3.3. Trouble falling or staying asleep; or sleeping too much|
<*Answer_4256*>|75. Probable depression diagnosis:| <*Answer_4257*>|76. Co-occurring conditions (Check all that apply):| <*Answer_4288*>|77. Indications for using antidepressants (Check all
that apply):| <*Answer_4260*>|78. Indications for referral for psychotherapy (Check all that apply):| <*Answer_4261*>|79. Mental Health Specialty Referral:| <*Answer_4262*>|80. Care Plan
suggestions (Check all that apply):| <*Answer_4263*>|81. Suggested Labs (Check all that apply):| <*Answer_4289*>|82. Comments for Primary Care summary:| <*Answer_4264*>|83. Plan for Care
Manager (Check all that apply):| <*Answer_4265*>|84. Comments on Care Manager Plan:| <*Answer_4266*>|85. Previously sent material:| <*Answer_4267*>|86. Self-help plan in place?|
<*Answer_4268*>|87. Is patient doing self-help activities?| <*Answer_4269*>|88. Information offered and encouragement (Check all that apply):| <*Answer_4270*>|89. Information to be mailed
(Check all that apply):| <*Answer_4271*>|90. Possible barriers to learning (Check all that apply):| <*Answer_4272*>|91. Patient's preferred learning methods (Check all that apply):|
<*Answer_4273*>|92. Comments on self-care management and education:| <*Answer_4274*>|93. Best time to call:| <*Answer_4275*>|94. Best days to call:| <*Answer_4276*>|95. Best numbers to
call:| <*Answer_4277*>|96. Patient refuses further calls?| <*Answer_4278*>|97. Provider feedback to:| <*Answer_4286*>|98. Call history:| <*Answer_4280*>| $~
<*Answer_4537*>|3.3.1 Sleep disturbance:| <*Answer_4282*>|3.4. Feeling tired or having little energy:| <*Answer_4538*>|3.5. Poor appetite or overeating:| <*Answer_4539*>|3.5.1 Appetite
disturbance:| <*Answer_4283*>|3.6. Feeling bad about yourself:| <*Answer_4540*>|3.7. Trouble concentating on things:| <*Answer_4541*>|3.8. Moving or speaking slowly; or being fidgety or
restless:| <*Answer_4542*>|3.8.1 Psycho-motor disturbance:| <*Answer_4284*>|3.9. Thoughts that you would be better off dead or of hurting yourself in some way:| <*Answer_4552*>|4. Number of
symptoms present:| <*Answer_4190*>|5. Major Depression Disorder trigger symptoms:| <*Answer_4191*>|6. Initial Symptom Difficulty: Symptoms make work/home/getting along difficult?|
<*Answer_4192*>|7. Comments on depression screening:| <*Answer_4194*>|8. Suicidial ideation (Check all that apply):| <*Answer_4195*>|9. Other risk factors for suicide (Check all that apply):|
<*Answer_4196*>|10. Is the VA Medical Center suicide policy initiated?| <*Answer_4197*>|11. Suicidal ideation management (Check all that apply):| <*Answer_4193*>|12. Homicidal ideation
|
