33 (33)    MH REPORT (601.93)

.|.|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