DOUGLAS COUNTY PUBLIC HEALTH GROUP, INC



DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC - AVA, MO

504 NW 10th Ave. Federal ID#:

AVA, MO 65608 Invoice #:

Date: Ins # 1

Pt. Name: Time: ID # 1

Address: Pt. No: Ins # 2

Phone: SS #: ID # 2

Pt. DOB: Co Pay: $ Balance:

PSYCHIATRIC DIAGNOSTIC/EVALUATION PANIC DISORDER

__90801 Psychiatric DX interview __W/Agrophobia (300.21)

__90804 Ind Psychotherapy 20-30 min __W/O Agrophobia (300.01)

__90806 Ind Psychotherapy 45-50 min BIPOLAR I D/O Most recent episode depressed

__90810 Interactive Psych 20-30 min __Full Remission (296.56)

__90812 Interactive Psych 45-50 min __Partial Remission (296.55)

__90846 Family Psych w/o pt present __NOS Bipolar D/O (296.80)

__90847 Family Psych w/pt present __Bipolar II D/O (296.89)

__90853 Group Therapy MAJOR DEPRESSIVE D/O-RECURRENT

__90887 Data Result Interpretation __Full Remission (296.36)

__90889 Report Preparation __Partial Remission (296.35)

ADJUSTMENT DISORDERS __Mild (296.31)

__Unspecified (309.9) __Moderate (296.32)

__W/Anxiety (309.24) __Severe w/o Psychotic (296.33)

__W/Depress Mood (309.0) __Severe with Psychotic (296.34)

__W/Distrubing Conduct (309.3) __Unspecified (296.30)

__Mix. Anx/Depress Mood (309.28) MAJOR DEPRESSIVE D/O-SINGLE

__Mix. Dist/Emotions/Conduct (309.4) __Full Remission (296.26)

ANXIETY __Partial Remission (296.25)

__Generalized (300.02) __Mild (296.21)

__D/O due to Medical (293.89) __Moderate (296.22)

__NOS (300.00) __Severe w/o Psychotic (296.23)

ALCOHOL __Severe with Psychotic (296.24)

__Abuse (305.00) __Unspecified (296.20)

AMPHETAMINE OTHER DISORDERS

__Abuse (305.70) __Dependence (304.40) __Anorexia Nervosa (307.1)

CANNABIS __Bulemia Nervosa (307.51)

__Abuse (305.20) __Dependence (304.30) __Dysthymic Disorder (300.4)

COCAINE __Impulse Control NOS (312.30)

__Abuse (305.60) __Dependence (304.20) __Learning Disorder (315.9)

ATTENTION DEFICIT/HYPERACTIVE D/O __Mood Disorder NOS (296.90)

__Combined Type (314.01) __Obsessive Comp. D/O (300.3)

__Predom. Hyperactive-Impulse (314.01) __Oppositional Defiant D/O (313.81)

__Predominately Inattentive (314.00) __Post Traumatic Stress D/O (309.81)

__Attn. Def-Hyper D/O NOS (314.9) ________________________________

# Initially Authorized Visits ____

# Used ____

Provider: # Remaining (Include. Today) ____

__CANCELLATION __NO SHOW __RESCHEDULE

RETURN VISIT: __No __Yes Time Needed: _______________

Douglas County Public Health Services Group, Inc.

GERIATRIC FUNCTIONAL LIVING ASSESSMENT

FINANCIAL FACTORS Yes No

1. Are you able to afford medicine or medical supplies? [] []

2. Are you able to afford medical co-payments or deductibles? [] []

3. Are you able to afford rent/utility bills? [] []

4. Are you able to afford food? [] []

NEURO/EMOTIONAL/BEHAVIOR FACTORS HIGH RISK FACTORS

[] Alert/oriented able to focus and shift attention [] Smoking

comprehends and recalls task directions independently. [] Obesity

[] Requires prompting only under stressful or unfamiliar [] Alcohol dependence

conditions. [] Drug dependence

[] Requires considerable assistance in routine situations. [] Other:__________________

Is not alert/oriented.

[] Totally dependent due to disturbance such as constant disorientation or delirium.

[] Reports the following depressive feelings

[] Depressed mood

[] Sense of failure or self reproach

[] Hopelessness

[] Recurrent thought of death

[] Thoughts of suicide

[] None of the above

The following behaviors are demonstrated at least once per week:

[] Indecisiveness [] Diminished interest in most activities

[] Sleep disturbances [] Recent change in appetite or weight

[] Agitation [] Impaired decision making

[] Memory deficit [] Verbal disruption

[] Physical aggression [] Delusional, hallucinatory or paranoid behavior

LIVING ARRANGEMENTS

1. Where do you live?

[] Own home (alone)

[] Own home (with spouse or significant other)

[] Boarding home or rented room

[] Assisted living facility

2. Do you have structural barriers or safety hazards in your residence such as:

[] Stairs which must be used daily with no railings

[] Narrow or obstructed doorways

[] Inadequate floor, roof, windows or lighting

[] Inadequate heating or cooling

[] Lack of running water or toilet facilities

3. Do you require assistance with any of the following:

[] Transportation [] Preparing meals [] Shopping

[] Administering medications [] Housekeeping and/or laundry

[] Administering finances [] Personal hygiene (bathing, dressing)

Client referred to the following services: _____________________________________________________

_______________________________________________________________________________________________

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