Doctor: Good afternoon, sir. Is this your mother? 
Patient: Good afternoon, doctor. Yes, this is my mom. 
Doctor: Great, please, give me some background information on your history. 
Patient: Well, I used to live here in the city when I went to college, but I wanted to get away from a bad crowd, so I came back to live with my mom. 
Doctor: What do you mean, bad crowd? 
Patient: Well, I got addicted to drugs out there, and I used to inject heroin. 
Doctor: Did you see a doctor for this addiction? 
Patient: Yeah, I saw another doctor in the city. 
Doctor: How did they treat you at that time? 
Patient: They prescribed me methadone for a while. 
Doctor: Did that help at all?
Patient: Honestly, no, it didn't help at all. 
Doctor: Do you remember the dosage that you were given? 
Patient: Um, it was ten M G. 
Doctor: How long did you take methadone for? 
Patient: Um, it was for three or four months. 
Doctor: Did you ever try to decrease your dosage? 
Patient: Yeah, um, I tried to wean off it for a while, but I was never really successful. 
Doctor: Have you been using heroin since? 
Patient: Um, yeah, I've been using it occasionally. 
Doctor: Were you roommates at school using drugs? 
Patient: Yeah, so it's hard to get away from the stuff, it was all over the house. 
Guest_family: Well, he can now, especially because he lives with me. 
Doctor: Good, when was the last time you used heroin? 
Patient: Um, it's been about eight days now. 
Doctor: Good, congratulations. When was the last time you had methadone? 
Patient: Um, it's been about a week for that now, too. Am I able to get more today?
Doctor: We can discuss that. Have you had any feelings of depression recently? 
Patient: Yeah, I feel down and sad a lot. 
Doctor: What about your energy? 
Patient: I really don't have much. 
Doctor: What about your enthusiasm for the foods or activities you enjoy? 
Guest_family: He hasn't had much enthusiasm for anything, either. 
Doctor: Are you having any suicidal or homicidal thoughts or actions at this time?
Guest_family: No, nothing like that, doctor. 
Doctor: Good, what about delusions, hallucinations, or disorganized thoughts or behaviors? 
Patient: No, nothing like that either, doctor. 
Doctor: Do you have any medical conditions in the past that I should know about? 
Patient: No, not that I know of. 
Guest_family: No, he hasn't been treated for anything before, doctor. 
Doctor: You completed your family and social history earlier with the nurses, is there anything you want to add to that? 
Patient: No, everything there is complete. 
Doctor: Do you have any allergies? 
Patient: No, I don't have any. 
Doctor: Good, and do you take any medications right now? 
Patient: No, doctor. I don't take anything. 
Doctor: Have you had any surgeries in the past?
Patient: I voluntarily donated my left kidney.

Clinical note:
Symptoms: Depression, sadness, low energy, lack of enthusiasm
Diagnosis: History of heroin addiction, history of methadone use, depression
History of Patient: Patient previously lived in the city and became addicted to drugs, specifically heroin, received methadone treatment which was not effective, attempted to wean off methadone unsuccessfully, currently living with mother to avoid drug environment, last heroin use approximately eight days ago, last methadone use approximately one week ago, presenting today requesting methadone, denies suicidal or homicidal ideations, denies Symptoms of bipolar disorder, no significant past medical history except for voluntary left kidney donation
Plan of Action: Further evaluation and discussion regarding methadone treatment, assessment and management of depression, referral to appropriate resources for addiction treatment and mental health support