| PATIENT'S CALL HISTORY |
| Today's Date: 08/10/2000 |
| Patient ID: 1234567 |
| C O P E |
| Patient Report |
| Call Description |
| Call Date |
| Depression |
| Scale * |
| Work/Social |
| Adjustment |
| Scale ** |
| Patient Global |
| Impression of |
| Improvement + |
| FAX FOR: Physician Name |
| Medication |
| Compliance |
| Welcome Call |
| 11/29/1999 |
| Getting Started |
| 16 |
| 25 |
| NOT ASKED |
| 11/29/1999 |
| YES |
| Assertive Communications |
| 12/03/1999 |
| Pleasant Activities Call One |
| 12/03/1999 |
| Pleasant Activities Call Two |
| 13 |
| 28 |
| 4 |
| 12/08/1999 |
| YES |
| Pleasant Activities Call Three |
| 8 |
| 22 |
| 4 |
| 01/02/2000 |
| YES |
| PATIENT REPORTED AT BASELINE |
| Patient |
| a buddy or a friend to help them as they progress through treatment. |
| COPE seems |
| First Module recommended by COPE : |
| First Module Selected by Patient : |
| IS NOT |
| DOES NOT HAVE |
| JUST OKAY |
| grieving |
| Patient |
| ASSERTIVE COMMUNICATION |
| ASSERTIVE COMMUNICATION |
| * Depression Scale: |
| 1 Very Much Better |
| 2 Much Better |
| 3 A Little Better |
| 4 About the Same |
| 5 A Little Worse |
| 6 Much Worse |
| 7 Very Much Worse |
| + PGI of Improvement : |
| 0-5 Not significantly impaired |
| 6-12 Slightly impaired |
| 13-25 Definitely Impaired |
| 26-35 Markedly Impaired |
| 36-40 Very Severely Impaired |
| ** Work and Social Adjustment Scale: |
| 0-3 Normal Range |
| 4-7 Subclinical |
| 8-10 Mild |
| 11-14 Moderate |
| 15-21 Severe |
| Healthcare Technology Systems, Inc. • 7617 Mineral Point Road, Suite 300 • Madison, WI 53717 |
| Phone : (608) 827-2440 • Fax (608) 827-2444 |
| www.healthtechsys.com |
| © 2000 Healthcare Technology Systems, Inc. |
| This report is only an adjunctive tool for your use in assessing your patient's progress. |
| Keys for Scales: |