contrib/forms/mh_therapy_progress/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: mh_therapy_progress");
   5 ?>
   6 <html><head>
   7 <?php html_header_show();?>
   8 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11 <form method=post action="<?php echo $rootdir;?>/forms/mh_therapy_progress/save.php?mode=new" name="my_form">
  12 <br>
  13 <span class="title"><center>Therapy Progress Note</center></span><br><br>
  14 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  15 <img src="../../../images/space.gif" width="5" height="1">
  16 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
  17  onclick="top.restoreSession()">[Don't Save]</a></center>
  18 <br>
  19
  20 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  21 $result = SqlFetchArray($res); ?>
  22 <b><u>A. Client and meeting Information</u></b><br><br>
  23 <b>Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  24 <img src="../../../images/space.gif" width="125" height="1">
  25 <b>Date:</b>&nbsp; <?php print date('m/d/y'); ?>
  26 <img src="../../../images/space.gif" width="72" height="1">
  27 <b>Time In:</b>&nbsp;<input type="text" name="time_in">
  28 <img src="../../../images/space.gif" width="14" height="1">
  29 <b>Time Out:</b>&nbsp;<input type="text" name="time_out"><br><br>
  30
  31 <b>Meeting was:</b>&nbsp;<input type=checkbox name='meeting_scheduled'><b>Scheduled</b>
  32 <img src="../../../images/space.gif" width="6" height="1">
  33 <input type=checkbox name='meeting_emergency'><b>Emergency</b>
  34 <img src="../../../images/space.gif" width="12" height="1">
  35 <b>Others Present</b><img src="../../../images/space.gif" width="6" height="1">
  36 <textarea cols=55 rows=1 wrap=virtual name="others_present" ></textarea><br><br>
  37
  38 <b>Meeting lasted:</b>&nbsp;<input type="text" name="meeting_lasted">&nbsp;<b>minutes</b>
  39 <img src="../../../images/space.gif" width="18" height="1">
  40 <b>Number of Units</b>&nbsp;<input type="text" name="number_of_units">
  41 <img src="../../../images/space.gif" width="18" height="1">
  42 <b>ICD-9 Diagnosis</b>&nbsp;<input type="text" name="icd9"><br><br>
  43
  44 <b>Client:</b>&nbsp;<input type=checkbox name='client_ontime'><b>Was on time</b>
  45 <img src="../../../images/space.gif" width="6" height="1">
  46 <input type=checkbox name='client_late'><b>Was late by</b>
  47 <img src="../../../images/space.gif" width="6" height="1">
  48 <input type="text" name="was_late_by">
  49 <img src="../../../images/space.gif" width="6" height="1">
  50 <b>min.</b>
  51 <img src="../../../images/space.gif" width="6" height="1">
  52 <input type=checkbox name='did_not_show'>&nbsp;<b>Did not show</b>
  53 <img src="../../../images/space.gif" width="6" height="1">
  54 <input type=checkbox name='cancelled'>&nbsp;<b>Cancelled</b>
  55 <img src="../../../images/space.gif" width="18" height="1">
  56 <b>Next Meeting</b>
  57 <img src="../../../images/space.gif" width="6" height="1">
  58 <input type="text" name="next_meeting"><br><br>
  59
  60 <b>Location:</b>&nbsp;
  61 <input type=checkbox name='location_office'>&nbsp;<b>Office</b>
  62 <img src="../../../images/space.gif" width="6" height="1">
  63 <input type=checkbox name='location_detention'>&nbsp;<b>Detention</b>
  64 <img src="../../../images/space.gif" width="6" height="1">
  65 <input type=checkbox name='location_home'>&nbsp;<b>Home</b>
  66 <img src="../../../images/space.gif" width="6" height="1">
  67 <input type=checkbox name='location_school'>&nbsp;<b>School</b>
  68 <img src="../../../images/space.gif" width="6" height="1">
  69 <input type=checkbox name='location_hosp'>&nbsp;<b>Hosp.</b>
  70 <img src="../../../images/space.gif" width="6" height="1">
  71 <input type=checkbox name='location_other'>&nbsp;<b>Other</b>
  72 <img src="../../../images/space.gif" width="6" height="1">
  73 <input type="text" name="location_other_block">
  74 <img src="../../../images/space.gif" width="6" height="1">
  75 <b>Facility Code:</b>
  76 <img src="../../../images/space.gif" width="6" height="1">
  77 <input type="text" name="location_facility_code"><br><br>
  78
  79 <b>Treatment:</b>
  80 <img src="../../../images/space.gif" width="6" height="1">
  81 <input type=checkbox name='treatment_individual_therapy'>&nbsp;<b>Individual therapy</b>
  82 <img src="../../../images/space.gif" width="6" height="1">
  83 <input type=checkbox name='treatment_family'>&nbsp;<b>Family</b>
  84 <img src="../../../images/space.gif" width="6" height="1">
  85 <input type=checkbox name='treatment_group'>&nbsp;<b>Group</b>
  86 <img src="../../../images/space.gif" width="6" height="1">
  87 <input type=checkbox name='treatment_couple'>&nbsp;<b>Couple</b>
  88 <img src="../../../images/space.gif" width="6" height="1">
  89 <input type=checkbox name='treatment_assessment'>&nbsp;<b>Assessment</b>
  90 <img src="../../../images/space.gif" width="6" height="1">
  91 <b>Service Code:</b>
  92 <img src="../../../images/space.gif" width="6" height="1">
  93 <input type="text" name="treatment_service_code"><br><br>
  94
  95 <b>Pay Source:</b>
  96 <img src="../../../images/space.gif" width="6" height="1">
  97 <input type=checkbox name='paysource_medicaid'>&nbsp;<b>Medicaid</b>
  98 <img src="../../../images/space.gif" width="6" height="1">
  99 <input type=checkbox name='paysource_dfs'>&nbsp;<b>DFS</b>
 100 <img src="../../../images/space.gif" width="6" height="1">
 101 <input type=checkbox name='paysource_private'>&nbsp;<b>Private</b>
 102 <img src="../../../images/space.gif" width="6" height="1">
 103 <input type=checkbox name='paysource_other'>&nbsp;<b>Other</b>
 104 <img src="../../../images/space.gif" width="6" height="1">
 105 <input type="text" name="paysource_other_block">
 106 <img src="../../../images/space.gif" width="18" height="1">
 107 <b>County:</b>
 108 <img src="../../../images/space.gif" width="6" height="1">
 109 <input type="text" name="paysource_county"><br><br>
 110
 111 <br>
 112 <b><u>B. Topic of Discussion (Content)</u></b><br>
 113 <textarea cols=120 rows=7 wrap=virtual name="topics_of_discussion" ></textarea><br><br>
 114
 115 <b><u>C. Progress Toward Goals (Process)</u></b><br>
 116 <textarea cols=120 rows=7 wrap=virtual name="progress_towards_goals" ></textarea><br><br>
 117
 118 <b><u>D. Client Description and Assessment</u></b><br><br>
 119
 120 <b>Medications:</b>
 121 <img src="../../../images/space.gif" width="6" height="1">
 122 <textarea cols=107 rows=1 wrap=virtual name="medications" ></textarea><br><br>
 123
 124 <b>Report of Functioning since last session:</b>
 125 <img src="../../../images/space.gif" width="6" height="1">
 126 <textarea cols=84 rows=1 wrap=virtual name="functioning_since_session" ></textarea><br><br>
 127
 128 <b>Mood:</b>
 129 <img src="../../../images/space.gif" width="6" height="1">
 130 <input type=checkbox name='mood_normal'>&nbsp;<b>Normal/euthymic</b>
 131 <img src="../../../images/space.gif" width="6" height="1">
 132 <input type=checkbox name='mood_anxious'>&nbsp;<b>Anxious</b>
 133 <img src="../../../images/space.gif" width="6" height="1">
 134 <input type=checkbox name='mood_depressed'>&nbsp;<b>Depressed</b>
 135 <img src="../../../images/space.gif" width="6" height="1">
 136 <input type=checkbox name='mood_angry'>&nbsp;<b>Angry</b>
 137 <img src="../../../images/space.gif" width="6" height="1">
 138 <input type=checkbox name='mood_euphoric'>&nbsp;<b>Euphoric</b><br><br>
 139
 140 <b>Affect:</b>
 141 <img src="../../../images/space.gif" width="6" height="1">
 142 <input type=checkbox name='affect_normal'>&nbsp;<b>Normal/appropriate</b>
 143 <img src="../../../images/space.gif" width="6" height="1">
 144 <input type=checkbox name='affect_intense'>&nbsp;<b>Intense</b>
 145 <img src="../../../images/space.gif" width="6" height="1">
 146 <input type=checkbox name='affect_blunted'>&nbsp;<b>Blunted</b>
 147 <img src="../../../images/space.gif" width="6" height="1">
 148 <input type=checkbox name='affect_inappropriate'>&nbsp;<b>Inappropriate</b>
 149 <img src="../../../images/space.gif" width="6" height="1">
 150 <input type=checkbox name='affect_labile'>&nbsp;<b>Labile</b><br><br>
 151
 152 <b>Mental status:</b>
 153 <img src="../../../images/space.gif" width="6" height="1">
 154 <input type=checkbox name='mentalstatus_normal'>&nbsp;<b>Normal</b>
 155 <img src="../../../images/space.gif" width="6" height="1">
 156 <input type=checkbox name='mentalstatus_lessened_awareness'>&nbsp;<b>Lessened awareness</b>
 157 <img src="../../../images/space.gif" width="6" height="1">
 158 <input type=checkbox name='mentalstatus_memory_deficiencies'>&nbsp;<b>Memory Deficiencies</b>
 159 <img src="../../../images/space.gif" width="6" height="1">
 160 <input type=checkbox name='mentalstatus_disorientated'>&nbsp;<b>Disoriented</b>
 161 <img src="../../../images/space.gif" width="6" height="1">
 162 <br><input type=checkbox name='mentalstatus_disorganized'>&nbsp;<b>Disorganized</b>
 163 <img src="../../../images/space.gif" width="6" height="1">
 164 <input type=checkbox name='mentalstatus_vigilant'>&nbsp;<b>Vigilant</b>
 165 <img src="../../../images/space.gif" width="6" height="1">
 166 <input type=checkbox name='mentalstatus_delusional'>&nbsp;<b>Delusional</b>
 167 <img src="../../../images/space.gif" width="6" height="1">
 168 <input type=checkbox name='mentalstatus_hallucinating'>&nbsp;<b>Hallucinating</b>
 169 <img src="../../../images/space.gif" width="6" height="1">
 170 <input type=checkbox name='mentalstatus_other'>&nbsp;<b>Other:</b>
 171 <img src="../../../images/space.gif" width="6" height="1">
 172 <input type="text" name="mentalstatus_other_block"><br><br>
 173
 174 <b>Suicide/violence risk:</b>
 175 <img src="../../../images/space.gif" width="6" height="1">
 176 <input type=checkbox name='suicide_violance_risk_none'>&nbsp;<b>None</b>
 177 <img src="../../../images/space.gif" width="6" height="1">
 178 <input type=checkbox name='suicide_violance_risk_ideation_only'>&nbsp;<b>Ideation only</b>
 179 <img src="../../../images/space.gif" width="6" height="1">
 180 <input type=checkbox name='suicide_violance_risk_threat'>&nbsp;<b>Threat</b>
 181 <img src="../../../images/space.gif" width="6" height="1">
 182 <input type=checkbox name='suicide_violance_risk_gesture'>&nbsp;<b>Gesture</b>
 183 <img src="../../../images/space.gif" width="6" height="1">
 184 <input type=checkbox name='suicide_violance_risk_rehearsal'>&nbsp;<b>Rehearsal</b>
 185 <img src="../../../images/space.gif" width="6" height="1">
 186 <input type=checkbox name='suicide_violance_risk_attempt'>&nbsp;<b>Attempt</b><br><br>
 187
 188 <b>Sleep quality:</b>
 189 <img src="../../../images/space.gif" width="6" height="1">
 190 <input type=checkbox name='sleep_quality_normal'>&nbsp;<b>Normal</b>
 191 <img src="../../../images/space.gif" width="6" height="1">
 192 <input type=checkbox name='sleep_quality_restless'>&nbsp;<b>Restless</b>
 193 <img src="../../../images/space.gif" width="6" height="1">
 194 <input type=checkbox name='sleep_quality_insomnia'>&nbsp;<b>Insomnia</b>
 195 <img src="../../../images/space.gif" width="6" height="1">
 196 <input type=checkbox name='sleep_quality_nightmares'>&nbsp;<b>Nightmares</b>
 197 <img src="../../../images/space.gif" width="6" height="1">
 198 <input type=checkbox name='sleep_quality_oversleeps'>&nbsp;<b>Oversleeps</b><br><br>
 199
 200 <b>Participation level:</b>
 201 <img src="../../../images/space.gif" width="6" height="1">
 202 <input type=checkbox name='participation_level_active'>&nbsp;<b>Active/eager</b>
 203 <img src="../../../images/space.gif" width="6" height="1">
 204 <input type=checkbox name='participation_level_variable'>&nbsp;<b>Variable</b>
 205 <img src="../../../images/space.gif" width="6" height="1">
 206 <input type=checkbox name='participation_level_only_responsive'>&nbsp;<b>Only responsive</b>
 207 <img src="../../../images/space.gif" width="6" height="1">
 208 <input type=checkbox name='participation_level_minimal'>&nbsp;<b>Minimal</b>
 209 <img src="../../../images/space.gif" width="6" height="1">
 210 <input type=checkbox name='participation_level_none'>&nbsp;<b>None</b>
 211 <img src="../../../images/space.gif" width="6" height="1">
 212 <input type=checkbox name='participation_level_resistant'>&nbsp;<b>Resistant</b>
 213 <br><br>
 214
 215 <b>Treatment_compliance:</b>
 216 <img src="../../../images/space.gif" width="6" height="1">
 217 <input type=checkbox name='treatment_compliance_full'>&nbsp;<b>Full</b>
 218 <img src="../../../images/space.gif" width="6" height="1">
 219 <input type=checkbox name='treatment_compliance_partial'>&nbsp;<b>Partial</b>
 220 <img src="../../../images/space.gif" width="6" height="1">
 221 <input type=checkbox name='treatment_compliance_low'>&nbsp;<b>Low</b><br><br>
 222
 223 <b>Response to treatment:</b>
 224 <img src="../../../images/space.gif" width="6" height="1">
 225 <input type=checkbox name='response_to_treatment_as_expected'>&nbsp;<b>As expected</b>
 226 <img src="../../../images/space.gif" width="6" height="1">
 227 <input type=checkbox name='response_to_treatment_better'>&nbsp;<b>Better than expected</b>
 228 <img src="../../../images/space.gif" width="6" height="1">
 229 <input type=checkbox name='response_to_treatment_much'>&nbsp;<b>Much</b>
 230 <img src="../../../images/space.gif" width="6" height="1">
 231 <input type=checkbox name='response_to_treatment_poorer'>&nbsp;<b>Poorer</b>
 232 <img src="../../../images/space.gif" width="6" height="1">
 233 <input type=checkbox name='response_to_treatment_very_poor'>&nbsp;<b>Very poor</b><br><br>
 234
 235 <b>GAF (Global Assessment of Functioning) from 100 to 0 is currently:</b>
 236 <img src="../../../images/space.gif" width="6" height="1">
 237 <input type="text" name="gaf"><br><br>
 238
 239 <b>Other observations/evaluations:</b>
 240 <img src="../../../images/space.gif" width="12" height="1">
 241 <textarea cols=83 rows=1 wrap=virtual name="other_observations" ></textarea><br><br>
 242
 243 <b>Changes to diagnosis:</b>
 244 <img src="../../../images/space.gif" width="6" height="1">
 245 <input type=checkbox name='diagnosis_changes_none'>&nbsp;<b>None</b>
 246 <img src="../../../images/space.gif" width="6" height="1">
 247 <textarea cols=83 rows=1 wrap=virtual name="diagnosis_changes" ></textarea><br><br>
 248
 249 <h5><b>If treatment was changed, Indicate rational, alternatives considered/rejected/selected in notes.</b></h5>
 250
 251 <b>G. Follow-Ups</b><br><br>
 252
 253 <input type=checkbox name='followups_next'>
 254 <img src="../../../images/space.gif" width="6" height="1">
 255 <b>Next appointment is scheduled for:</b>
 256 <input type="text" name='followups_next_date'>
 257 <img src="../../../images/space.gif" width="6" height="1">
 258 <input type=checkbox name='followups_next_week'>&nbsp;<b>Week</b>
 259 <img src="../../../images/space.gif" width="6" height="1">
 260 <input type=checkbox name='followups_next_month'>&nbsp;<b>Month</b>
 261 <img src="../../../images/space.gif" width="6" height="1">
 262 <input type=checkbox name='followups_next_2_months'>&nbsp;<b>2 Months</b>
 263 <img src="../../../images/space.gif" width="6" height="1">
 264 <input type=checkbox name='followups_next_3_months'>&nbsp;<b>3 Months</b>
 265 <img src="../../../images/space.gif" width="6" height="1">
 266 <input type=checkbox name='followups_next_as_needed'>&nbsp;<b>as needed</b><br><br>
 267
 268 <input type=checkbox name='followups_referral'>
 269 <img src="../../../images/space.gif" width="6" height="1">
 270 <b>Referral/consultation to:</b>
 271 <img src="../../../images/space.gif" width="6" height="1">
 272 <input type="text" name='followups_referral_to'>
 273 <img src="../../../images/space.gif" width="6" height="1">
 274 <b>For:</b>
 275 <img src="../../../images/space.gif" width="6" height="1">
 276 <input type="text" name='followups_referral_for'><br><br>
 277
 278 <input type=checkbox name='followups_call'>
 279 <img src="../../../images/space.gif" width="6" height="1">
 280 <b>Call/write to:</b>
 281 <img src="../../../images/space.gif" width="6" height="1">
 282 <input type="text" name='followups_call_to'>
 283 <img src="../../../images/space.gif" width="6" height="1">
 284 <b>For:</b>
 285 <img src="../../../images/space.gif" width="6" height="1">
 286 <input type="text" name='followups_call_for'><br>
 287
 288
 289
 290
 291
 292
 293 <br><br>
 294 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 295 <img src="../../../images/space.gif" width="5" height="1">
 296 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 297  onclick="top.restoreSession()">[Don't Save]</a></center>
 298 <br>
 299 </form>
 300 <?php
 301 formFooter();
 302 ?>