Tic Disorder/Tourette Syndrome Clinic Note

Date: [Date]

Encounter Type: [new / follow-up]

Patient: [Patient name/identifier]

Participants: [Patient, family members, interpreter if used]

Referral Question/Today's Goals: [Stated goals or reason for referral]

Chief Complaint

[One-line reason for visit] (For new visits, capture presenting tic symptoms and concerns. For follow-ups, include diagnosis and what is being managed, e.g., "Tourette syndrome follow-up—tics and ADHD management.")

Brief Identifying Statement

[Age, relevant context, and why seen now] (Include for new evaluations; omit if redundant for routine follow-ups.)

History of Present Illness

[Narrative paragraph with onset age, recent changes, patient/family concerns and goals, and currently most impairing symptoms]

Tic Description: [Onset and evolution; current motor tics with body regions, complexity, frequency, intensity, pain/injury; current vocal/phonic tics with similar features; premonitory urge presence and character; suppressibility and rebound effects; triggers/modifiers including stress, fatigue, attention, screens, sleep, medications; contextual variability between home vs school/work and alone vs observed; safety-relevant tics including self-injurious behaviors or tic attacks]

Impairment: [School/learning impacts including handwriting, test performance, attendance, disciplinary issues; social impacts including bullying, peer reactions, isolation, embarrassment; physical impacts including pain, injury, fatigue; family functioning impacts] (Quantify when possible; specify whether due to tics vs comorbid symptoms.)

Comorbidity Screen:

• ADHD: [Inattention, hyperactivity/impulsivity, executive function symptoms—present / absent / suspected]
• OCD spectrum: [Obsessions, compulsions, just-right phenomena] (Clarify tic vs compulsion if uncertain.)
• Anxiety: [Generalized, social, separation anxiety symptoms]
• Mood: [Depression, irritability symptoms]
• Sleep: [Sleep disturbance and relationship to tics]
• Safety screening: [Suicidal ideation and self-harm risk assessment] (If not completed, state: Not assessed—[reason].)
• Substance use: [Caffeine, nicotine, cannabis, other] (For adolescents/adults.)

Prior Treatments: [Behavioral therapy trials including CBIT/HRT, ERP, CBT with response and current status; medications tried for tics or comorbidities with response, adverse effects, and reason stopped; other strategies including relaxation, sleep hygiene, accommodations]

Current School Supports: [504 plan, IEP, or informal accommodations in place; what has helped vs not helped; requests for provider letters] (Include for students.)

Past History

• Medical: [Neurologic conditions, head injury, sleep disorders]
• Psychiatric: [Prior diagnoses and treatment]
• Developmental: [Milestones, concerns] (Brief unless new evaluation.)
• Family: [Tics, OCD, ADHD, anxiety disorders in relatives]
• Social: [Living situation, grade/occupation, supports, stressors]

(For follow-up visits, include interval updates only.)

Medications and Allergies

Current Medications: [Medication list with doses—include ADHD medications, SSRIs, antipsychotics, alpha-2 agonists, supplements]

Allergies: [Allergen and reaction type]

Examination

Vitals: [HR, BP, weight/BMI] (BP especially important if alpha-2 agonists used; weight/BMI especially important if antipsychotics used.)

Physical Exam: [General appearance; evidence of injuries from tics]

Neurologic Exam: [Mental status; relevant cranial nerves; motor/tone/coordination/gait findings as appropriate]

Tic Observation: [Tics observed during visit with motor and vocal types, frequency, intensity] (If no tics observed, explicitly note absence and whether suppression suspected. If family reports severe tics but none observed, note intermittency/suppressibility and whether video review or collateral is needed.)

Behavioral Observations: [Mood and affect; anxiety level; attention/impulsivity observed; insight]

Instruments and Data Reviewed

(Include only when standardized measures, external records, or videos were reviewed; otherwise omit section.)

• [Instrument names with scores and dates—brief interpretation]
• [School/teacher rating scales or neuropsychological reports—brief interpretation]
• [External records summarized]
• [Family-provided videos reviewed—brief interpretation]

Assessment

[Diagnostic formulation with working/confirmed tic diagnosis, severity and impairment summary, key comorbidities driving impairment, and differential considerations if applicable]

• Diagnosis: [Tic disorder type—provisional / persistent; motor and/or vocal tics; onset timing; exclusion of other causes] (Do not infer if criteria uncertain—document what is unconfirmed and plan to clarify.)
• Severity/Impairment: [Summary by domains]
• Comorbidities: [Key comorbidities and contribution to impairment]
• Differential: [Considerations including functional tic-like behaviors if atypical features present] (Include only if relevant.)

Plan

(Organize by problem, listing most impactful problems first. Omit subsections that do not apply.)

Tic Disorder

Treatment Indication: [Active treatment indicated / watchful waiting appropriate]—[Patient/family preference]

Education: [Counseling provided regarding natural history with waxing/waning and age-related trajectory; normalizing suppressibility and variability; stigma reduction strategies]

Behavioral Therapy: [CBIT/HRT or ERP discussed; availability; decision: accepted / declined with reason / already engaged; referral information if made; if declined or unavailable, document alternative supports and plan to revisit]

Medication: (Include only if prescribing or actively considering.)

• Indication: [Tic severity and/or comorbidity profile]
• Agent: [Selection and rationale considering comorbidities and side-effect profile]
• Dosing: [Starting dose and titration plan]
• Counseling: [Key adverse effects reviewed] (If not counseled: Not counseled—[reason].)
• Monitoring: [BP/HR for alpha-2 agonists; weight/BMI and metabolic labs for antipsychotics; EPS monitoring]
• Safety instructions: [When to contact clinic or stop medication]

ADHD

(Include if ADHD symptoms present or suspected.)

[Screening results and functional impact; coordination plan with other providers; medication considerations with observed/reported effect on tics]

OCD

(Include if OCD symptoms present.)

[Clarification of tic vs compulsion; therapy plan including CBT with ERP if indicated; psychiatry coordination]

Anxiety/Depression

(Include if present.)

[Screening results and severity; safety plan if suicidal ideation or self-harm risk identified; therapy and/or psychiatry referral plan] (If safety not assessed: Not assessed—[reason].)

Sleep

(Include if sleep problems affect symptoms.)

[Sleep issues and relationship to symptom control; sleep hygiene counseling; further evaluation or treatment plan]

School Supports

(Include for students with school-related impairment.)

[School letter provided with content summary; recommendations for 504 plan or IEP; specific accommodations including testing accommodations, seating, breaks, reduced penalties for tic-related behaviors, anti-bullying supports, staff education; plan for parent/school follow-up]

Atypical Features/Differential

(Include only if diagnostic uncertainty or concern for functional tic-like behaviors.)

[Specific atypical features prompting reconsideration; diagnostic plan including video review, collateral information, specialty referral]

Follow-Up

Referrals: [CBIT provider, psychology, psychiatry, neuropsych testing, school liaison]

Orders: [Labs or studies with timing]

Follow-up: [Timing and format; specific triggers to return earlier]