Anxiety Soap Note Professional
Prepared by: [Your Name]
I. Subjective
A. Chief Complaint
The patient reports feeling "constant anxiety" that interferes with daily activities, including work and social interactions.
B. History of Present Illness
The patient states that the anxiety began approximately six months ago and has progressively worsened. Symptoms include excessive worry, irritability, difficulty concentrating, and trouble sleeping. Stressful work conditions and personal issues are identified as potential triggers.
C. Past Medical History
No history of mental health conditions was reported. Denies the use of medications for anxiety or prior therapy.
D. Social History
The patient lives alone, works full-time as a teacher, and has minimal social interaction outside work. Limited support network reported.
II. Objective
A. Observations | B. Vital Signs |
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The patient appeared tense and restless during the session. Speech was normal but occasionally hesitated when describing symptoms. No observable signs of acute distress.
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III. Assessment
A. Diagnosis
Generalized Anxiety Disorder (GAD), moderate severity, as indicated by the patient’s reported symptoms and clinical observations.
B. Clinical Summary
The patient presents with persistent anxiety and related symptoms consistent with GAD, likely exacerbated by external stressors and insufficient coping mechanisms.
IV. Plan
A. Treatment Goals
B. Interventions
Psychotherapy: Begin cognitive-behavioral therapy (CBT) weekly for 12 weeks.
Lifestyle Modifications: Encourage regular physical activity, mindfulness exercises, and maintaining a consistent sleep schedule.
Medication Evaluation: Referral to a psychiatrist for evaluation of the need for anti-anxiety medication.
C. Follow-Up
Schedule a follow-up session in two weeks to evaluate initial progress and adjust the treatment plan as necessary.
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