Mental Health Record

Patient Information

Field	Details
Patient Name:	Antonette Cassin
Age:	65
Gender:	Female
Address:	Moreno Valley, CA 92551
Phone Number:	222 555 7777
Emergency Contact:	Ben Cassin
Relationship:	Husband
Primary Care Physician:	Dr. Sarah Green
Referring Physician:	Dr. Michael White

Presenting Problem

• Date of Consultation: March 4, 2095

• Reason for Visit: Patient reports feelings of depression and memory loss.

• Symptoms Reported: Persistent sadness, difficulty concentrating, forgetfulness.

• Duration of Symptoms: Symptoms present for the past 6 months.

Mental Health History

• Past Diagnoses: Depression, Anxiety Disorder (diagnosed in 2050)

• Previous Treatments: Cognitive Behavioral Therapy (CBT) 2050-2055, Antidepressant Medication (Fluoxetine)

• Medications: Currently on antidepressant (Sertraline, 50mg daily).

• Hospitalizations: Hospitalized for depression in 2052.

• Therapy/ Counseling History: Attended therapy intermittently from 2050-2055.

Mental Health Assessment

Area	Observations and Notes
Mood	Low mood, reports feeling sad most days.
Affect	Blunted affect, limited emotional expression.
Thought Content	No evidence of delusions or hallucinations, but reports constant worry.
Perception	No perceptual disturbances noted.
Cognition	Mild cognitive impairment, difficulty with short-term memory.
Memory	Impaired recall of recent events.
Judgment/Insight	Fair judgment, insight into condition is somewhat limited.
Risk Assessment	No current risk of self-harm or harm to others.

Diagnosis

• Primary Diagnosis: Major Depressive Disorder (MDD)

• Secondary Diagnosis: Mild Cognitive Impairment (MCI)

Treatment Plan

• Goals: Improve mood, reduce depressive symptoms, enhance cognitive functioning.

• Interventions: Weekly cognitive-behavioral therapy (CBT) sessions, continue Sertraline, consider neuropsychological testing.

• Medications Prescribed: Increase Sertraline dosage to 100mg daily.

• Referrals: Referred to Neurologist for further cognitive assessment.

• Follow-up Plan: Follow-up appointment in 2 weeks for medication review and therapy update.

Notes and Recommendations

Encourage patient to engage in regular physical activity to support mental health. Recommend social support groups for elderly individuals with cognitive concerns.

Provider Information

• Provider Name: Dr. [YOUR NAME], [YOUR COMPANY NAME]

• Title/Role: Licensed Clinical Psychologist

• Date: March 4, 2095

Medical Record Templates @ Template.net