02/22/2005
IDENTIFYING DATA:
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
PAST PSYCHIATRIC HISTORY:
PAST MEDICAL HISTORY:
ALLERGIES: NKDA
FAMILY HISTORY:
PSYCHOSOCIAL HISTORY:
MEDICATIONS:
REVIEW OF SYSTEMS:
Immunologic:      denied symptoms of consistent with immune disorder
Cardiovascular:   denied dyspnea, orthopnea, arrythmia, syncopy, edema
Constitutional:   denied fever, weight loss, sweats, and fatigue
ENT:              denied sore throat, dysphagia, nasal congestion
Endocrine:        denied thyroid problems
Eyes:             denied change in vision
Gastrointestinal: denied diarrhea, constipation, RBPR, coffee ground
Genitourinary:    denied dysuria, blood in urine, incontinence
Hematological:    denied hematological diseases, lymphadenopathy
Musculoskeletal:  denied musculoskeletal pain, weakness
Neurologic:       denied limb weakness, dizziness, change in vision
ALL OTHERS NEGATIVE
PHYSICAL EXAM:
VITAL SIGNS:
GENERAL:
HENT:
CVS:
LUNGS:
ABDOMEN:
NEURO:
LABORATORY DATA: pending
MENTAL STATUS EXAMINATION:
ASSESSMENT AND PLAN:
DIAGNOSIS:
AXIS I:
AXIS II:
AXIS III:
PLAN:
DIAGNOSTIC WORKUP:
Health maintenance issues:
Disposition:
LENGTH OF ENCOUNTER:
Date:  02/22/05
________________________________________________

***** Notes Number 1 created 02/22/2005 3:35 PM

PSYCHOTHERAPY (TREATMENT) FOLLOW-UP NOTES

Activity since last visit:
Date:  02/22/05    Time Began:  15: 2  Time Ended:  15:32
Location:  Office:       Hospital:
Procedure Code:
Current Problems:
Symptoms requiring level of care:
Environmental Stressors:
Goals of current therapy:
Response to therapy in terms of goals:
New issues:
Therapeutic interventions used during session:
Medical issues and LAB values:
Pharmacotherapy:
Issues for next session:
Other:
Level of collaboration:
Date of next session:  03/01/05
Signed:
________________________________________________