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 ChiefComplaint: 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Violent behavior Anxiety or excessive worries Sleep difficulties Academic/school-related problems Depression or being withdrawn Suicide thoughts or behavior Hearing voices that others cannot hear Odd, strange or unusual behavior Mood swings, "moody", or crying spells or "giggly" Not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
Expenses that ARE NOT Covered Under Niagara Falls City School District’s Health Flexible Spending or Health Reimbursement Account Over-the-counter products *physician’s prescription required to be eligible for the majority of over-the-counter products Prescription is good for one year from the date it was written, and will need to be resubmitted annually. Medical Expense
Canada Product Ingredients This list is compiled based on product information provided by Subway® approved food manufacturers. Every effort is made to keep this information current however it is possible that ingredient changes and substitutions may occur before this list is updated. This list does not include regional or special promotional items as ingredients vary. BREADS
Sample Report Description 
Date of Report - 9/26/2007 
Clinicom Diagnoses Reviewed By Clinician