DVMH

Da Vinci Mental Health

OCD Assessment & Treatment Module

Progress

Please complete all sections below as thoroughly as possible. Fields marked * are required.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Used to file this form with the correct patient record. (Not part of the original paper form.)

Date*

Section 1 - OCD Screen (OCI-R)

Over the past month, how much have you been distressed or bothered by the following?*

(0 = Not at all | 1 = A little | 2 = Moderately | 3 = A lot | 4 = Extremely)

Obsessions & Compulsions

Question	0	1	2	3	4

Total Score (out of 28)

Functional impairment present (clinician judgment)

Section 2 - Y-BOCS Style Severity (Hybrid Self-Report)

Obsessions

Compulsions

Severity Score (0-40)

Interpretation

Scoring: 0-7 Subclinical | 8-15 Mild | 16-23 Moderate | 24-31 Severe | 32-40 Extreme

Section 3 - Functional Impairment

Daily Function

Cognitive Impact

Sleep Impact

Section 5 - Clinician Summary (MDM Support)

For clinician completion.

Y-BOCS Interpretation: -

Functional Impairment (from Section 3): -

OCD Severity

Calculated automatically from the Y-BOCS Severity Score above.

Functional Impairment

Calculated automatically from Work Impairment and Social Avoidance in Section 3 (whichever is greater).

Risk Level

Automatically suggested based on OCD severity and functional impairment above. Please confirm or adjust as clinically appropriate -- this is a starting suggestion, not a determination.

Low Moderate High

Impression

Obsessive-Compulsive Disorder with: Automatically suggested from the Y-BOCS Obsessions vs. Compulsions subscores above. Please confirm or adjust as clinically appropriate.

Predominantly obsessions Predominantly compulsions Mixed presentation

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Thank you

Your assessment has been received. Our office will follow up if anything further is needed.