eCareHealth EHR · Patient Visit History

Robert Fox (M)

ID :2480

10-07-1990 (32Yrs)

3 Allergies Risk 0.28

569-822-4144

PST

English

robertfox@gmail.com

8642 Yule Street, Arvada CO 80007

Diabetic Blood Pressure

Primary Provider: Mark Wood, MD

Last Visit: 07-06-2025, 18:30

Upcoming Appointment: 08-09-2025, 13:15

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To-Do Actions (40)

Today, 01/01/2025

In Progress: Unsigned Office Visit Note

by Dr. Corina, MD

In Progress: Lab Order: Anti-Striated Muscle Screen Reflex Titer (CLH 4825)

In Progress: New: Vitamin D3 125 MCG (5000 UT) Cap 1 capsule orally daily #30 capsule R5

In Progress: Letter to John Doe

Yesterday, 12/31/2024

In Progress: New: Vitamin D3 125 MCG (5000 UT) Cap 1 capsule orally daily #30 capsule R5

In Progress: Unsigned Office Visit Note

by Dr. Corina, MD

12/30/2024

In Progress: Unsigned Phone Note

by Dr. Corina, MD

In Progress: Unsigned Office Visit Note

by Dr. Corina, MD

Care History

Visit Note

Forms & Assessment

Simple SOAP Note

Visit Note Template

Visit Time :Fri, Apr 16, 2025 12:32 PM

Appointment Type :In-person Visit

Chief Complaint (CC) :

Subjective

Patient reports persistent low mood over the past several weeks. Describes lack of motivation, difficulty concentrating, and changes in appetite and sleep patterns (hypersomnia). Denies suicidal ideation at this time.

Objective

Vital signs within normal limits. No acute physical findings on examination. Patient appears withdrawn but cooperative. Affect is flat, and speech is normal in rate and tone.

Assessment

(ICD-10 Code: F33.1) Major Depressive Disorder, Moderate

Plan

Initiate Sertraline 50 mg daily
Recommend cognitive behavioral therapy (CBT)
Discussed importance of sleep hygiene and regular exercise