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Sample Report Description
This document is a sample of an actual CliniCom™ report. This report has been de-identified in compliance with HIPAA privacy policies. This report is exactly what all CliniCom™ Doctors see when their patients complete the CliniCom™ digital intake and assessment. This sample report helps demonstrate the capacity that CliniCom™ has for thoroughly assessing patients for mental illnesses. Keep in mind that while the report format remains the same, the depth and scope of each CliniCom™ report varies based on the patient’s condition and the severity of their case. Case Background
Sex: Female
Chief Complaint: Depression

History: This is a 15 year old female presenting with depression, hopelessness
and hallucinations. She has tried a few medications in the past and has been
hospitalized twice for psychiatric care. She has experienced sexual abuse in
the past. Has side effects from current medication.
Date of Report - 9/26/2007
Final Assessment
BIOGRAPHICAL DATA
01. User Information
02. Identification
Who will bring the child to the interview? CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666
CHIEF COMPLAINT

03. Presenting Problem

HISTORY OF PRESENT ILLNESS

04. History of present Illness
Past medication Support of loved ones Support of friends Hearing voices that tell her to hurt herself and hurt others. She goes into a dazed type state and does not act like herself. She seems angry. Irritability / Anger / Rages Violent behavior Anxiety or excessive worries Sleep difficulties Academic/school-related problems Depression or being withdrawn Suicide thoughts or behavior Hearing voices that others cannot hear Odd, strange or unusual behavior Mood swings, "moody", or crying spells or "giggly" Not talking or communicating as expected Difficulty remembering familiar people or events, not feeling like his/her self, time loss, like in trance Symptoms - 314 Inattention
4. Does not follow through on directions 6. Avoids tasks that require mental effort 7. Loses things necessary for activities Symptoms - 314.01 Hyperactivity / Impulsivity
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 4. Difficulty performing activities quietly 5. Often "driven by a motor" (on the go) 9. Often interrupts or intrudes on others Symptoms - 313.81 Oppositional Defiant Disorder
Symptoms - 300.23 Social Phobia
Symptoms - 300.01 Panic Attacks
Symptoms - 309.81 Posttraumatic Stress
to similar situations as traumatic event Symptoms - 296.2 Major Depression
Depressed mood or sadness nearly every day for a long period of time (several months at a time) CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 6. Often fatigued or tired for no apparent She has mentioned that she knows how she can kill herself if she ever wanted to. Symptoms - 296.00 Manic Episode
5. Flight of ideas (jumps from one topic 8. Excessive pleasurable activities with Symptoms - 312.8 Conduct Disorder
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 Symptoms - 300.02 Overanxious / Generalized Anxiety Disorder
1. Excessive worries, restlessness or feeling on edge for more than six 3. Difficulty concentrating or mind going Symptoms - 309.21 Separation Anxiety Disorder
6. Afraid to go to sleep without parent or Symptoms - 300.30 Obsessive Compulsive Disorder
3. Often tries to ignore such thoughts, impulses or images, but cannot control Symptoms - 315.90 Learning disabilities
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 Symptoms - 307.40 Sleep Disorder
Symptoms - 299.00 Autistic / 299.80 Aspergers Disorders
2. Failure to develop peer relationships 4. Lack of social or emotional reciprocity 5. Delay or total lack of development of 6. If adequate speech, inability to initiate Symptoms - 295.1 Schizophrenia
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 Symptoms - 312.30 Impulse Control Disorder
Symptoms - 307.90 Communication Disorder
5. Difficulty expressing himself/herself Symptoms - 300.15 Dissociative Disorder
1. Inability to recall important personal 2. Significant distress or impairment at 3. Confusion about personal identity or assuming a new identity (partial or 5. Persistent or recurrent experiences of feeling detached from and as if one is an outside observer of one's mental processes or body Symptoms - 313.23 Selective Mutism
1. Consistent failure to speak in specific 05. Treatment History

CURRENT TREATMENTS

06. Current Treatment
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 Anxiety Appetite decrease Depression Hallucinations Nausea Sleeping problems Stomach discomfort Suicidal thoughts Vomiting Weight loss
DEVELOPMENT

07. Conception and Pregnancy
08. Birth
09. Development
By what age was the child toilet trained? CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 10. Sexual Development
11. Early temperament
Patterns of regulation as a baby/toddler 12. Adoption

PAST MEDICAL HISTORY

13. Past Psychiatric History
History of hospitalization for psychiatric Name of Hospital Admission Date Discharge Date Reason 14. Physical Health History
fell and hit head when was 4 months old and fractured skull
ALLERGIES

15. Allergies

FAMILY HISTORY

16. Family History
Paternal grandmother Paternal Uncle(s) Paternal Aunt(s) Maternal grandfather Maternal grandmother CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 Behavior problem Difficulty paying attention Hyperactivity Violence assaultive Mood swings Anxiety or excessive worries Concerned with body weight Anger Bizarre behavior Maternal grandfather Maternal grandmother Maternal Uncle(s) Maternal Aunt(s) Mother
SOCIAL HISTORY

17. Support System
loss of employement, moving to a better area, moving to where a better job is available. CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 19. Safety
She was 3 years old and was visiting with her Grandfather, he called her into the bedroom and pulled her pants down and touched her privates. Then when she was 10 years old an older boy tried to sexually assult her by pulling her pants down and getting on top of her trying to sexually assault her but she managed to get away from him. This was a grandfather of a friend. Then when she was 13 a close friend and classmate's Grandfather started touching her breasts and her privates, then her friend entered the room and he stopped. She never went back to the house. 20. Substance Abuse
21. Stressors
Divorce Sexual abuse Bullied at school Change in personal routines Starting or stopping formal education Major change in social activities Major change in sleeping habits 22. Education
23. Employment
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 24. Leisure
Plays video games or computer games Watches TV Has hobbies Plays sports 25. Legal
26. Adjustment
CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666 Clinicom Diagnoses Reviewed By Clinician
300.4 Dysthymic Disorder
Accepted by Clinician
307.40 Sleep Disorders
Accepted by Clinician
312.9 Disruptive Behavior Disorder NOS
Accepted by Clinician
Diagnoses Added By Clinician
309.81 Posttraumatic Stress Disorder
Clinical impression
Clinician Signature: _________________________________________________ Date: _______________________ Assessed By Signature: _____________________________________________ Date: _______________________ CliniCom Report Generator v 1.0 Copyright HARMONEX 2004 (www.harmonex.us/clinicom) Diagnostic and treatment decisions should always be made by a qualified licensed professional following a CliniCom Assessment Turner , Christine ID: 666666

Source: http://www.harmonex.us/documents/Child-Depression-Female.pdf

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