HM Adult Patient Progress Report

Harmonious Mind (Psychiatric and Counseling Services)

5189 W. Woodmill Dr., St.30, Wilmington, DE 19808. On the Web: www.HarmoniousMind.com

Tel: 302.633.6001 Fax: 302.295.6289 SMS/Text: 302.565.4818 Email: Support@HarmoniousMind.com

Today's Date

Full Name

Date of Birth

Insurance

Pharmacy Name and Tel.

Have you had any health related changed since your last visit?

Yes No

Are you or a family member involved in a court case?

Yes

If yes, provide details.

Provide details of open/active court case or legal issues or any kind.

Describe your sleep; include if there is trouble falling asleep or waking up a lot at night. Any scary dreams?

Any Changes to your weight?

Yes No

Describe your appetite.

How has your energy levels been ?

How has your mood been?

Have you experienced crying or withdrawal from others?

Have you had thoughts of harming yourself

Yes No

If yes, provide details.

Do you have any plans of harming yourself or others?

How do you cope with thoughts of hurting or harming yourself?

Have you had feelings of hopelessness?

Any symptoms of Elated Moods since the last visit?

Have you been aggressive? Verbally or Physically?

Aggressiveness towards people or property?

Have you had thoughts of running away?

Have you had any scary or angry inner voices or visions?

Have you had trouble trusting?

Yes No

If Yes, provide details.

Have you had feelings of agitation?

Yes No

If yes, provide details.

Have you had feelings of paranoia?

Yes No

If yes, provide details

Sense of being outside or pulled into your body?

Yes No

Any panic attacks or anxiety ?

Any fear of being out in car, in store, or in presence of others, or in crowds?

Any urges to steal, gamble, spend, fire-set?

Any memory problems?

Any confusion spells?

yes no

Any Medication Changes?

Yes No

If yes, provide details.

Emergency Visit to ER or Doctor?

Yes No

If yes, Provide details.

Any New Stresses - Changes in school, work, home, family, relationships, peer, etc.

Overall progress or worsening of symptoms

Any side-effects from psychiatric medications?

Are you using alcohol or any illicit drugs?

What have you been working with your therapist on?

Describe any other General Symptoms - Aches, pain, muscle stiffness, etc. - Eyes - ENT - Cardiovascular – Palpitations, etc - Respiratory - Gastrointestinal - Genitourinary - Muscular - Integumentry - Neurological - Endocrine - Hemotologic - Allergies

Questions you may like to ask the doctor about medicines? Other concerns you may have?

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Date Signed

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