templatesdbinit.sql

PatientRunner 20 Source

  author varchar(80) default NULL,
  PRIMARY KEY  (templateid)
) TYPE=MyISAM;

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LOCK TABLES templates WRITE;
INSERT INTO templates VALUES (1,'Ad Sep for Adj D/O','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier New;}{\\f1\\fnil MS Sans Serif;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\keepn\\qc\\lang1023\\f0\\fs24 Naval Medical Center\r\n\\par \\pard\\ltrpar\\qc Department of Psychiatry\r\n\\par \\pard\\ltrpar\\keepn\\qc ANYTOWN, ST 12345\r\n\\par \\pard\\ltrpar \r\n\\par \\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab <DATE>\r\n\\par \r\n\\par From:  LT F. M. LASTNAME, MC, USNR\r\n\\par To:    Commanding Officer, <COMMAND>\r\n\\par \r\n\\par Subj:  ICO <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, 20/<SSN>\r\n\\par \r\n\\par 1.\\tab We recommend administrative separation by Reason of Convenience of the Government in accordance with MILPERSMAN article 1910-120.  The patient suffers from an Adjustment Disorder.  This is the development of emotional or behavioral symptoms in response to an identifiable stressor that results in significant impairment in occupational or social functioning.  This condition does not amount to a disability per current Navy guidance however it renders her incapable or completing her obligated service in any capacity.\r\n\\par \r\n\\par 2.\\tab Please contact me with any questions at [phone].\r\n\\par \r\n\\par \r\n\\par Very Respectfully,\r\n\\par \r\n\\par \r\n\\par F. M. Lastname\r\n\\par LT, MC, USNR\\lang1033\\f1\\fs16 \r\n\\par \r\n\\par }\r\n\0','root'),(2,'Ad Sep (Entry Lvl)','{\\rtf1\\fbidis\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier New;}{\\f1\\fnil\\fcharset0 MS Sans Serif;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\keepn\\qc\\lang1023\\f0\\fs24 Naval Medical Center\r\n\\par \\pard\\ltrpar\\qc Department of Psychiatry\r\n\\par \\pard\\ltrpar\\keepn\\qc ANYTOWN, ST 12345\r\n\\par \\pard\\ltrpar \r\n\\par \\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab <DATE>\r\n\\par \r\n\\par From:  LT F. M. LASTNAME, MC, USNR\r\n\\par To:    Commanding Officer, <COMMAND>\r\n\\par \r\n\\par Subj:  ICO <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, 20/<SSN>\r\n\\par \r\n\\par 1.\\tab We recommend administrative separation by Reason of Entry Level Performance and Conduct in accordance with MILPERSMAN article 1910-154.  The patient suffers from an Adjustment Disorder.  This member is unqualified for futher naval service by reason of incapability, lack of reasonable effort, failure to adapt to the naval environment and/or minor disciplinary infarctions.\r\n\\par \r\n\\par \r\n\\par 2.\\tab Please contact me with any questions at [phone].\r\n\\par \r\n\\par \r\n\\par Very Respectfully,\r\n\\par \r\n\\par \r\n\\par F. M. Lastname\r\n\\par LT, MC, USNR\\lang1033\\f1\\fs16 \r\n\\par \\lang1023\\f0\\fs24 \r\n\\par }\r\n\0','root'),(3,'Ad Sep (PD)','{\\rtf1\\fbidis\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier New;}{\\f1\\fnil\\fcharset0 MS Sans Serif;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\keepn\\qc\\lang1023\\f0\\fs24 Naval Medical Center\r\n\\par \\pard\\ltrpar\\qc Department of Psychiatry\r\n\\par \\pard\\ltrpar\\keepn\\qc ANYTOWN, ST 12345\r\n\\par \\pard\\ltrpar \r\n\\par \\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab <DATE>\r\n\\par \r\n\\par From:  LT F. M. LASTNAME, MC, USNR\r\n\\par To:    Commanding Officer, <COMMAND>\r\n\\par \r\n\\par Subj:  ICO <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, 20/<SSN>\r\n\\par \r\n\\par 1.  We recommend administrative separation by Reason of Convenience of the Government in accordance with MILPERSMAN article 1910-122.  The patient suffers from a Personality Disorder.  This is a longstanding disorder of character manifested by disturbances of cognition, affectivity, interpersonal functioning and impulse control.  The member\'s performance of duty and ability to function effectively in the Naval environment is significantly impaired.\r\n\\par \r\n\\par 2.  The patient is considered to be self-destructive and is a continuing danger to self or others.  \r\n\\par \r\n\\par 3.  Please contact me with any questions at [phone].\r\n\\par \r\n\\par Very Respectfully,\r\n\\par \r\n\\par \r\n\\par F. M. Lastname\r\n\\par LT, MC, USNR\\lang1033\\f1\\fs16 \r\n\\par \\lang1023\\f0\\fs24 \r\n\\par }\r\n\0','root'),(4,'BCNR','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier New;}{\\f1\\froman\\fprq2\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\tqc\\tx4680\\lang1023\\f0\\fs24 Template for starting format for BCNR - SUBJ LINE SHOULD BE ON EACH PAGE AT THE TOP AND PRIVACY ACT PROTECTED - FOR OFFICIAL USE ONLY ON EACH PAGE AT BOTTOM,WITH PAGE # IN THE CENTER OF PAGE 2 AND ALL OTHER PAGES. \r\n\\par \r\n\\par \\tab DEPARTMENT OF PSYCHIATRY\r\n\\par \\tab NAVAL MEDICAL CENTER\r\n\\par \\tab ANYTOWN, ST 12345\r\n\\par \\pard\\ltrpar\\fi6480 \r\n\\par       6520\r\n\\par       0421:\\i doc #\\i0\\f1 \r\n\\par \\pard\\ltrpar\\f0                                                  <\\i date>\\i0\\f1 \r\n\\par \\i\\f0 \r\n\\par \\i0 From:  Case Reviewers\r\n\\par To:    Chairman, Board for Correction of Naval Records,\r\n\\par        Department of the Navy, Washington, D.C. 20370-2197\r\n\\par \r\n\\par Subj:  REQUEST FOR COMMENTS AND RECOMMENDATIONS IN CASE OF <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, 20/<SSN> \r\n\\par        \r\n\\par Ref:   (a) Your letter dated  \r\n\\par \r\n\\par Encl:  (1) BCNR file\r\n\\par        (2) Service Record \r\n\\par        (3) Medical Record \r\n\\par \\f1 \r\n\\par \\f0 1.\\tab Pursuant to reference (a) a review of enclosures (1) through (3) was conducted to form opinions about subject petitioner\'s claim that \r\n\\par \r\n\\par }\r\n\0','root'),(5,'Competency Board','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier;}{\\f1\\fmodern\\fcharset0 Courier New;}{\\f2\\froman\\fprq2\\fcharset0 Times New Roman;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\qc\\tqc\\tx4680\\lang1023\\f0\\fs24 NAVAL MEDICAL CENTER\r\n\\par DEPARTMENT OF PSYCHIATRY\r\n\\par ANYTOWN, ST 12345\r\n\\par REPORT OF COMPETENCY BOARD\r\n\\par \\pard\\ltrpar\\qj\\tqc\\tx4680 \r\n\\par \\tab\\tab\\tab\\tab\\tab\\tab <DATE>\r\n\\par \\pard\\ltrpar\\qj \r\n\\par From:  Competency Board\r\n\\par To:\\tab   Commander, Naval Medical Center, Portsmouth, Virginia\r\n\\par \r\n\\par Subj:  REPORT OF COMPETENCY BOARD \\f1 <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, <SSN>\\f2 \r\n\\par \\pard\\ltrpar\\qj\\f0 \r\n\\par Ref:\\tab   (a) Manual of the Medical Department, Chapter 18, Section 28\r\n\\par \\tab   (b) JAG Manual, Chapter 14, Paragraph 1404\r\n\\par \r\n\\par 1.  INTRODUCTION:  Pursuant to references (a) and (b), a competency board was convened in the case of <RATE> <LASTNAME> on <DATE>.\r\n\\par \r\n\\par 2.  HISTORY OF PRESENT ILLNESS:  \\f1 The history of present illness was obtained from available medical records and was considered reliable.  \\f2 \r\n\\par \\f0 \r\n\\par \\pard\\ltrpar 3.  MENTAL STATUS EXAMINATION:  \\f1 A&Ox3.  Appropriately dressed and well groomed.  PT was wearing civilian clothes.  Eye contact was good.  Mood euthymic.  Affect congruent.  Speech fluent with normal rate, rhythm and tone.  Thought process logical.  The PT denied SI, HI and AVH.  Memory and cognition grossly intact.  Insight and judgment intact.  MMSE 30/30\\f2 \r\n\\par \\pard\\ltrpar\\qj\\f0 \r\n\\par 4.  PRESENT STATUS: The patient is not able to communicate any understanding of the significance of his current physical impairments, treatment recommendations and prognosis regarding his medical care. He is not able to render decisions regarding treatment and anticipate the consequences of such decisions.  His death is considered imminent.\r\n\\par \r\n\\par 5.  Therefore, on <DATE>, the primary psychiatric diagnosis was established as:\r\n\\par \r\n\\par Cognitive Disorder NOS #294.9\r\n\\par \r\n\\par 6.  Medical Diagnoses include:\r\n\\par \r\n\\par 7.  FINDINGS: In accordance with reference (a) and (b), this board is of the opinion that the patient is not capable of managing his medical affairs.  \r\n\\par \\pard\\ltrpar\\f1 \r\n\\par }\r\n\0','root'),(6,'DONCAF','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier;}{\\f1\\froman\\fprq2\\fcharset0 Times New Roman;}{\\f2\\fmodern\\fcharset0 Courier New;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\qj\\tqc\\tx4680\\lang1023\\f0\\fs24\\tab \r\n\\par \\tab NAVAL MEDICAL CENTER\r\n\\par \\tab DEPARTMENT OF PSYCHIATRY\r\n\\par \\tab ANYTOWN, ST 12345\r\n\\par \\pard\\ltrpar\\qj \r\n\\par                                                   6520\r\n\\par                                                   0421:\\lang1024 (doc. no)\\lang1023\\f1 \r\n\\par \\f0                                                   <date>\r\n\\par \r\n\\par \r\n\\par From:  Head, Outpatient Psychiatry Division\r\n\\par To:    Director, Department of the Navy, Central Adjudication \r\n\\par        Facility, Washington Navy Yard, Washington, DC 20388-5029\r\n\\par Via:   Head, Psychiatry Department\r\n\\par \r\n\\par \\pard\\ltrpar Subj:  PSYCHIATRIC EVALUATION IN THE CASE OF \\f2 <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, 20/<SSN>\\f1 \r\n\\par \\pard\\ltrpar\\qj\\f0         \r\n\\par Ref:   (a) OPNAV INST 5510.1H\r\n\\par        (b) DONCAF ltr 5520 Ser 29AMI/SA-30645 dtd 25 AUG 93  \r\n\\par \r\n\\par 1.\\tab INTRODUCTION: This <age> year old <sex>, with approximately <cad> continuous active military service was seen \r\n\\par \r\n\\par 2.\\tab HISTORY OF PRESENT ILLNESS: The history of present illness was obtained from the individual, available records and reference (b).  \r\n\\par \r\n\\par 3.\\tab PAST HISTORY:  \r\n\\par \r\n\\par 4.\\tab MENTAL STATUS EXAMINATION: The mental status examination revealed an individual who was neat, clean, alert and cooperative. His speech was normal in rate, rhythm and volume.  He had good eye contact.  No hallucinations, delusions or illusions were noted. to.  He denied suicidal or homicidal ideation.  No psychomotor changes were noted.  Thoughts were linear.  Mood was euthymic.  Affect was full, reactive and appropriate.  Insight was good.  Judgment was adequate.  Mini-mental status examination was 28/28.  \r\n\\par \r\n\\par \\pard\\ltrpar 5.  RESPONSE TO QUESTIONS ASKED CONCERNING MENTAL EMOTIONAL CONDITIONS:  \r\n\\par \r\n\\par }\r\n\0','root'),(7,'New Eval','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier New;}{\\f1\\fmodern\\fcharset0 Courier;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\lang1023\\f0\\fs24 <date>\r\n\\par \r\n\\par CC:\r\n\\par \r\n\\par HPI:  The PT was a <age>-year old <sex>, with <cad> continuous active duty attached to <command>.  \r\n\\par \r\n\\par Review of Systems:\r\n\\par \r\n\\par Past Psychiatric History:\r\n\\par \r\n\\par Family Psychiatric History:\r\n\\par \r\n\\par Past Medical History:\r\n\\par \r\n\\par Meds:\r\n\\par \r\n\\par Allergies:  <ALLERGIES>\r\n\\par \r\n\\par Vitals:\r\n\\par \r\n\\par Labs:\r\n\\par \r\n\\par Social History:\r\n\\par \r\n\\par Substance History:\r\n\\par \r\n\\par MSE:  A&Ox3.  Appropriately dressed and well groomed.  PT was wearing civilian clothes.  Eye contact was good.  Mood euthymic.  Affect congruent.  Speech fluent with normal rate, rhythm and tone.  Thought process logical.  The PT denied SI, HI and AVH.  Memory and cognition grossly intact.  Insight and judgment intact.\r\n\\par \r\n\\par A/P:  <age> y/o <sex>\r\n\\par \r\n\\par I.\r\n\\par II.\r\n\\par III.\r\n\\par IV.\r\n\\par V.\r\n\\par \r\n\\par 1.\r\n\\par \\f1 \r\n\\par }\r\n\0','root'),(8,'Dictation','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fcharset0 Courier New;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\lang1023\\f0\\fs24 <date>\r\n\\par \r\n\\par The PT was a <age>-year old <sex> her for a diagnostic psychiatric evaluation.  The evaluation was performed and dictated.\r\n\\par \r\n\\par Diagnoses:\r\n\\par \r\n\\par Recommendations:\r\n\\par 1.\r\n\\par \r\n\\par }\r\n\0','root'),(9,'PEB','{\\rtf1\\fbidis\\ansi\\ansicpg1252\\deff0{\\fonttbl{\\f0\\fmodern\\fprq1\\fcharset0 Courier New;}{\\f1\\fmodern\\fcharset0 Courier;}{\\f2\\fmodern\\fprq1 Courier New;}{\\f3\\fmodern\\fcharset0 Courier New;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\qc\\tqc\\tx4680\\lang1023\\f0\\fs24 \r\n\\par \r\n\\par \\f1 NAVAL MEDICAL CENTER\r\n\\par DEPARTMENT OF PSYCHIATRY\r\n\\par ANYTOWN, ST 12345\\f0 \r\n\\par \\pard\\ltrpar\\keepn\\ri-716 \r\n\\par NAME:  <LASTNAME>, <FIRSTNAME>\r\n\\par RATE/RANK/SER:  <RATE>/<RANK>/<SERVICE>\r\n\\par SSN:  <SSN>\r\n\\par COMMAND:  <COMMAND>\r\n\\par \\pard\\ltrpar\\qj\\ul\\b \r\n\\par \\ulnone\\b0 INTRODUCTION: This was the first Naval Medical Center ANYTOWN psychiatric evaluation for this <AGE>-year old <male>, with <CAD> continuous active duty.  The patient was referred for\r\n\\par \\f2 \r\n\\par \\f0 HISTORY OF PRESENT ILLNESS: The history of present illness was obtained from the patient and available medical records and was considered reliable.  \r\n\\par \\f2 \r\n\\par \\f0 PAST PSYCHIATRIC HISTORY: \r\n\\par \\pard\\ltrpar\\fi720\\qj \r\n\\par \\pard\\ltrpar\\qj FAMILY PSYCHIATRIC HISTORY: \r\n\\par \\f2 \r\n\\par \\f0 PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS:  The past medical history and review of systems were non-contributory.\r\n\\par \\f2 \r\n\\par \\f0 MEDICATIONS:\r\n\\par \\f2 \r\n\\par \\f0 ALLERGIES: <ALLERGIES>\r\n\\par \\f2 \r\n\\par \\f0 SOCIAL HISTORY:\r\n\\par \\f2 \r\n\\par \\f0 SUBSTANCE HISTORY:\\tab The patient denied a history of alcohol, illicit drug or tobacco use.\r\n\\par \\f2 \r\n\\par \\pard\\ltrpar\\f0 MENTAL STATUS EXAMINATION:  A&Ox3.  Appropriately dressed and well groomed.  PT was wearing the uniform of the day.  Eye contact was good.  Mood euthymic.  Affect congruent.  Speech fluent with normal rate, rhythm and tone.  Thought process logical.  The PT denied SI, HI and AVH.  Memory and cognition grossly intact.  Insight and judgment intact.\r\n\\par \\pard\\ltrpar\\qj \r\n\\par PHYSICAL EXAMINATION/LABORATORY:\\tab A physical examination was not conducted in the Psychiatry department.\r\n\\par \\f2 \r\n\\par \\f0 TREATMENT COURSE:  \r\n\\par \\f2 \r\n\\par \\f0 FINDINGS:  A conference of staff psychiatrists reviewed the available records and current findings and agreed that the service member suffers from a condition that precludes <hisher> rendering any further useful military service.\r\n\\par \\f2 \r\n\\par \\f0 DIAGNOSES: \r\n\\par \r\n\\par AXIS I:\r\n\\par AXIS II:\r\n\\par AXIS III:\r\n\\par AXIS IV:\r\n\\par AXIS V:  GAF=\r\n\\par \r\n\\par IMPAIRMENT:\\tab The degree of industrial and military impairment is moderate. The degree of civilian performance impairment is mild.\r\n\\par \\f2 \r\n\\par \\f0 RECOMMENDED MEDICATIONS:  Continued psychopharmacological medication was advised for the future.  The level of medication required does not render <himher> so sedated as to impair his psychomotor activity.  <Heshe> takes the prescribed medication appropriately under supervision.  The patient had good insight into <hisher> illness and would be expected seek professional assistance should <hisher> symptoms recur.  \r\n\\par \\f2 \r\n\\par \\f0 RECOMMENDATIONS:\\tab Following a review of the clinical findings, the Medical Board is of the opinion that the patient suffers from a condition that did not exist prior to entry into the service.  The Medical Board recommends that the service member\'s case be referred to the Central Physical Evaluation Board.\r\n\\par \\pard\\ltrpar\\keepn\\sb240\\sa60\\qj DISPOSITION:\\tab The Medical Board is further of the opinion that the patient has now received the maximum benefit of military medical treatment and that this has not restored the patient to a duty status.  At the present time the service member is considered fully competent to be discharged to his own custody, does not constitute a danger to himself or others, and is not likely to become a public charge.\r\n\\par \\pard\\ltrpar\\qj \r\n\\par MENTAL COMPETENCY:\\tab The patient is mentally capable of handling his own financial affairs.\r\n\\par \\f2 \r\n\\par \\pard\\ltrpar\\f0 DISCIPLINARY STATUS: There is no known legal, disciplinary or administrative action pending.\r\n\\par \\f3 \r\n\\par }\r\n\0','root'),(10,'PEB SURREBUTAL','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fprq1\\fcharset0 Courier New;}{\\f1\\fmodern\\fprq1 Courier New;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\qc\\tqc\\tx4680\\lang1023\\f0\\fs24 NAVAL MEDICAL CENTER \\f1 \r\n\\par \\f0 PORTSMOUTH, VIRGINIA 23708-2197\\f1 \r\n\\par \\f0 REPORT OF MEDICAL BOARD\\f1 \r\n\\par \\f0 -SURREBUTTAL-\\f1 \r\n\\par \\pard\\ltrpar\\qj\\f0 \r\n\\par \\pard\\ltrpar\\keepn\\ri-716 NAME:  <LASTNAME>, <FIRSTNAME>\\f1 \r\n\\par \\f0 RATE/RANK/SER:  <RATE>/<RANK>/<SERVICE>\\f1 \r\n\\par \\f0 SSN:  <SSN>\\f1 \r\n\\par \\pard\\ltrpar\\qj\\f0 COMMAND:  <COMMAND>\\f1 \r\n\\par \\f0 \r\n\\par The patient has been informed of the findings and the recommendations of the Board and does desire to submit a statement in rebuttal.  Statement appended.\\f1 \r\n\\par \r\n\\par \\f0 SURREBUTTAL:  The Board has reviewed the member\'s rebuttal.  The Board submits the following for review:\\f1 \r\n\\par \r\n\\par \\f0 1.\\f1 \r\n\\par \r\n\\par \\f0 The findings and recommendations of the Board remain unchanged.\\f1 \r\n\\par \\pard\\ltrpar\\f0 \r\n\\par }\r\n\0','root'),(11,'SOAP Note','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fprq1\\fcharset0 Courier New;}{\\f1\\fmodern\\fprq1 Courier New;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\lang1023\\f0\\fs24 <date>\\f1 \r\n\\par \r\n\\par \\f0 S:\\f1 \r\n\\par \r\n\\par \\f0 O:\\f1 \r\n\\par \\f0 Vitals:\\f1 \r\n\\par \r\n\\par \\f0 Meds:\\f1 \r\n\\par \r\n\\par \\f0 Allergies:  <allergies>\\f1 \r\n\\par \r\n\\par \\f0 MSE:  A&Ox3.  Appropriately dressed and well groomed.  PT was wearing the uniform of the day.  Eye contact was good.  Mood euthymic.  Affect congruent.  Speech fluent with normal rate, rhythm and tone.  Thought process logical.  The PT denied SI, HI and AVH.  Memory and cognition grossly intact.  Insight and judgment intact.\\f1 \r\n\\par \r\n\\par \\f0 A/P:  <age> y/o <sex>\\f1 \r\n\\par \r\n\\par \\f0 1.\\f1 \r\n\\par \\f0 \r\n\\par }\r\n\0','root'),(12,'TDRL','{\\rtf1\\fbidis\\ansi\\deff0{\\fonttbl{\\f0\\fmodern\\fprq1\\fcharset0 Courier New;}{\\f1\\fmodern\\fprq1 Courier New;}}\r\n\\viewkind4\\uc1\\pard\\ltrpar\\lang1023\\f0\\fs24 \r\n\\par \\pard\\ltrpar\\keepn\\qc Naval Medical Center\\f1 \r\n\\par \\pard\\ltrpar\\qc\\f0 Department of Psychiatry\\f1 \r\n\\par \\pard\\ltrpar\\keepn\\qc\\f0 ANYTOWN, ST 12345\\f1 \r\n\\par \\pard\\ltrpar\\f0 \r\n\\par \\f1\\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab\\tab\\f0 <DATE>\\f1 \r\n\\par \r\n\\par \\f0 From:  Medical Board Division, Naval Medical Center\\f1 \r\n\\par \\f0 To:\\tab   Physical Evaluation Board, Room 309,\\f1 \r\n\\par \\pard\\ltrpar\\fi720\\f0   720 Kennon Street, SE,\\f1 \r\n\\par \\pard\\ltrpar\\f0        Washington, Navy Yard, Washington, DC 20375-5023\\f1 \r\n\\par \\f0 Via:\\tab   Commander, Naval Medical Center\\f1 \r\n\\par \r\n\\par \\f0 Subj:  REPORT OF PERIODIC PHYSICAL EXAMINATION ICO\\f1 \r\n\\par \\pard\\ltrpar\\fi720\\f0   <RATE> <FIRSTNAME> <LASTNAME> <SERVICE>, 20/<SSN>\\f1 \r\n\\par \\pard\\ltrpar\\f0 \r\n\\par Ref:\\tab   (a) BUPERS Order dated ___\\f1 \r\n\\par \\tab\\f0   (b) Report of Medical Board dated ___\\f1 \r\n\\par \r\n\\par \\f0 1.\\tab Subject member reported for a periodic physical examination in accordance with reference (a) on <DATE>.\\f1 \r\n\\par \r\n\\par \\f0 2.\\tab Attention is invited to reference (b), which contained the diagnosis(es) of:\\f1 \r\n\\par \r\n\\par \\tab\\f0   a.\\f1 \r\n\\par \\tab\\f0   b.\\f1 \r\n\\par \r\n\\par \\f0 3.  \\f1 \r\n\\par \\f0 Since placement on the Temporary Disability Retirement List, \\f1 \r\n\\par \\f0 Since the last periodic physical examination,\\f1 \r\n\\par \r\n\\par \\f0 the patient has worked as\\f1 \r\n\\par \\f0 the patient has been unemployed due to\\f1 \r\n\\par \r\n\\par \\f0 Pertinent history, treatment, hospitalizations:\\f1 \r\n\\par \r\n\\par \\f0 4.  PHYSICAL FINDINGS:  The patient\'s condition has not stabilized.  The prognosis is fair.  The degree of civilian social and occupational impairment is severe.\\f1 \r\n\\par \r\n\\par \\f0 5.  LABORATORY/X-RAY FINDINGS:  Not indicated.\\f1 \r\n\\par \r\n\\par \\f0 6.  MENTAL STATUS EXAMINATION:  A&Ox3.  Appropriately dressed and well groomed.  PT was wearing the uniform of the day.  Eye contact was good.  Mood euthymic.  Affect congruent.  Speech fluent with normal rate, rhythm and tone.  Thought process logical.  The PT denied SI, HI and AVH.  Memory and cognition grossly intact.  Insight and judgment intact.\\f1 \r\n\\par \\pard\\ltrpar\\tx360\\f0 \r\n\\par 7.  CONSULTATION REPORTS:  None indicated.\\f1 \r\n\\par \\pard\\ltrpar\\f0 \r\n\\par 8.  FINAL DIAGNOSES:  (1)\\f1 \r\n\\par \r\n\\par \\f0 9.  CONCLUSIONS:  This patient should remain on TDRL until the next appropriate time for his periodic physical examination.\\f1 \r\n\\par \r\n\\par \\f0 10.  Disclosure of this report and a personal appearance before a Physical Evaluation Board would not be deleterious to the physical or mental health of the patient.  \\f1 \r\n\\par \r\n\\par \\f0 11.  The patient is mentally competent and able to manage personal affairs. \\f1 \r\n\\par \r\n\\par \\f0 12.  Upon completion of the above studies, the patient was released in accordance with basic order.\\f1 \r\n\\par \\f0 \r\n\\par }\r\n\0','root');
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