/ / Past Medical History: Past Surgical History: Non-Psychiatric Medication List: Target Ordering Medication Dose Frequency Symptom(s) Provider The Service member’s current medical PCM is: Phone number: ( ) - Section 5: Psychiatric Treatment History Medication Management/Narrative – Summary/Labs Substance Abuse Treatment History: Substance: Duration of Service Member has a history of Yes substance abuse: No Sobriety Date: Service Member has completed a Program Name: Yes substance treatment program Level of Treatment: No (SARP/ASAP/etc): Completion Date: / / If Service Member has a history of substance without treatment for substance use, please explain the rationale: Current Psychiatric Medication List: Target Ordering Medication Dose Frequency Symptom(s) Provider
/ / Past Medical History: Past Surgical History: Non-Psychiatric Medication List: Medication Dose Frequency Target Symptom(s) Ordering Provider The Service member’s current medical PCM is: Phone number: ( ) - Section 5: Psychiatric Treatment History – Medication Management/Narrative Summary/Labs Substance Abuse Treatment History: Service Member has a history of substance abuse: Yes No Substance: Duration of Sobriety Date: Service Member has completed a substance treatment program (SARP/ASAP/etc): Yes No Program Name: Level of Treatment: Completion Date: / / If Service Member has a history of substance without treatment for substance use, please explain the rationale: Current Psychiatric Medication List: Medication Dose Frequency Target Symptom(s) Ordering Provider