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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