NEW PATIENT HEALTH HISTORY

Transcription

1 171 Madison, Suite 1000 NY, NY South Broadway, 4th Floor White Plains NY Canal St. #511B NY NY Office: Fax: NEW PATIENT HEALTH HISTORY Name: Date of Birth: Age: STATE CURRENT HEALTH CONCERN(S): FOR YOUR MOST PRESSING HEALTH CONCERN, PLEASE DESCRIBE THE FOLLOWING: Current Symptoms (be as descriptive as possible) What makes it better, what makes it worse? How did this condition start? What type of workup have you had (doctors seen, tests performed, etc.)? 1

2 What treatments have you tried? How well have they worked? CURRENT MEDICINES, SUPPLEMENTS, HERBS (w/ dosage please): CANNIBIS HISTORY Are you currently using marijuana? Yes No Age at first use of cannabis? Dosage (i.e. 2-3 puffs three times daily, or ¼ ounce per week) Delivery System (i.e. pipe, joint, vaporizer, tincture, etc.) High/Low Quality, Strain? Have you had any adverse affects from cannabis? Have you ever had a reaction from cannabis? anxiety, depression, paranoia, other CURRENT MEDICAL CARE: Primary Care Provider (name, practice name or location): Approximate date of last physical examination: by whom? Would you like us to send a copy of your office visit note to your PCP or other providers? YES NO I am or have been treated by a: Talk therapist Social worker Psychiatrist Pain specialist Heart specialist Nerve specialist Other health care professional(s) you are seeing and for what conditions: ALLERGIES? (include reactions to medicines): 2

3 PAST MEDICAL HISTORY: Please list all major illnesses, injuries, traumas (including emotional), and surgeries w/ year LIFESTYLE: I have finished: Middle School High School College Post-Graduate Degree I am: Employed Unemployed Disabled Other How many hours of sleep do you get a night? Trouble sleeping or sleeping too much? How many cups or glasses do you drink per day: water: milk: caffeinated beverages: How many alcoholic beverages do you drink per week: Tobacco: Drugs What substances have you used in the past: Cocaine Heroin RX drug abuse Mushrooms Acid Ecstasy ETOH Other How much exercise per week (what kind?) What do you do for fun? Any recent major life changes? FAMILY MEDICAL HISTORY: (please list any conditions that run in the family, indicate if alive or deceased) Mother Father Siblings

4 MEDICAL HISTORY CHECK every condition that you have ever had. EYES Failing vision Double or blurred vision Squinting/ crossed eyes/ Asymmetric gaze Eye pain Eye infections Lose place when reading Poor reading comprehension Eyestrain or fatigue from reading Headache from reading Glasses or contacts Monovision/Progressive lenses ENT Decreased hearing Loud voice Snoring/Mouth breathing Ringing/Buzzing in ears Ear infections Allergies/Hay fever/runny nose Sinus problems Nose bleeds Frequent sore throats Prolonged hoarseness Speech problems CARD-PULM Asthma Emphysema Chronic cough Bronchitis Pneumonia Tuberculosis Shortness of breath on exertion Shortness of breath on lying flat Chest pains Heart murmurs Palpitations Swollen ankles Fainting spells Leg pain when walking Varicose veins/phlebitis GI Eating disorder Recent loss of appetite Difficulty swallowing Heartburn Persistent nausea/vomiting Ulcers Chronic abdominal pain Recent change in bowel habits Diarrhea Constipation Black or tarry stools Red blood in stools Hemorrhoids Diverticulosis Gall bladder trouble Jaundice/Hepatitis Hernia ENDO Chronic fatigue Recent weight loss Excessive weight gain Thyroid disease Cancer Diabetes NEURO Convulsions/Seizure Stroke Tremors Muscle weakness Numbness/Tingling sensation Frequent headaches Clumsiness MS Joint pain Scoliosis/Kyphosis Arthritis Gout Cold or numb feet Involved in contact sports DERM Rashes Psoriasis Eczema Hives Unusual moles PSYCH/EMOTIONAL Difficulty Sleeping Nightmares Nervousness/Anxiety Stress Depression Memory loss Moodiness Phobias Nail biting/thumb sucking Bad temper/breath holding/ Jealousy ILLNESSES Mumps Measles German measles Chicken pox Polio Scarlet fever Rheumatic fever TB Meningitis HABITS Alcoholism Alcohol... Cigarette...packs/day Coffee/Tea...cups/day HEME Anemia Malaria Bruise easily/bleeding Mononucleosis Unexplained lumps Fever/Chills/Excessive sweating GU Bed wetting Bladder infections Kidney infection Pain on urination Poor control of urination Decreased force of urination Blood in urine Kidney stones Discharge from penis or vagina Sexually transmitted disease FEMALE ONLY: Number of pregnancies... Number of live births... Number of miscarriages... Method of birth control... Age of onset of menses... Flow: Light Moderate Heavy Period Not Regular Length of Flow... Length of Cycle... Pain/bleeding with intercourse PMS (medium to severe) STRESS Check any of the following that occurred in your family the past year: Marriage Births Serious illness Divorce Deaths Separation Job loss Move Other... DENTAL Orthodontic treatment Dental extractions Crowns Root canal work Fillings Bridgework Retainer/Night guard Gum problems

5 NEW PATIENT INFORMATION & CONSENT FORM Patient's name M F Birth Date Patient's address Telephones: home work cell single married other children Occupation Patient's employer or school Patient's Primary Care Physician (and/or Referring Physician) Emergency Contact Info: Name: Relationship: Phone: Referred by: I, understand that payment for services by this office is solely my responsibility, regardless of any insurance coverage I may have. I authorize the release of any medical or other information necessary to process insurance claims, or a release of records to medical review agencies as required by law. I voluntarily and knowingly consent to and request outpatient treatment, which may encompass diagnostic tests and medical treatments deemed appropriate by the treating physician. I understand that such services are to be performed by the attending physician or by assistants designated by said doctor. I further authorize and consent to assistants and other personnel, to undertake this service and care as indicated by my attending physician. Signature of Patient, Parent or Guardian Date 5

6 INFORMED CONSENT FOR USE OF MEDICAL MARIJUANA FROM DR. JUNELLA CHIN I am being evaluated for a physician s certification that I meet the criteria set forth in An Initiative Petition for a Law for the Compassionate Care Act Medical Use of Marijuana in effect. The physician will make this certification based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non-medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, growing of, transportation, sale/purchase and/or distribution of marijuana. I have been informed of and understand the following: [please initial each item]: 1. I must be a New York resident 18 years of age or older unless I obtain parental consent to obtain an approval of recommendation for the use of medicinal cannabis. 2. The federal government has classified marijuana as a Schedule I controlled substance. Schedule 1 substances are defined, in part, as having (1) a high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states which have modified their state laws to treat marijuana as a medicine. 3. Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the manufacture of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients (i.e., can vary in potency), impurities, contaminants, and substances in addition to Delta 9 THC, which is the primary psychoactive chemical component of marijuana. 4. The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly. I understand that if I drive while under the influence of marijuana, I can be arrested for driving under the influence. 5. Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, falling, low blood pressure, impairment of short-term memory, euphoria, difficulty in completing complex tasks, suppression of the body s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and/or restlessness. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgment. 6. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana. I also intend to plan on being gradually weaned through my prescribing physician of medications such as sleeping pills, anti-anxiety medications, pain medications, etc. that may become unnecessary as I am improving. I realize that using these medications during using marijuana may have additive effects also. I realize also that I may not become a candidate for medical marijuana again and become reinstated if my doctor feels that I have

7 not benefitted from it in ways such as needing less of my other medications, or other reasons in his professional opinion. 7. I agree to contact Dr. JUNELLA CHIN if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact you if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and/or friends. 8. Inhaling marijuana may cause respiratory problems and harm, including bronchitis, emphysema and laryngitis. In the opinion of many researchers, marijuana contains known carcinogens (chemicals that can cause cancer) and marijuana may increase the risk of respiratory diseases and cancers in the lung, mouth and tongue. In addition, marijuana contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop using it and report my symptoms to a physician. New York State only uses a vape product to avoid many of these situation but there could be still risks. 9. The risks, benefits and drug interactions of marijuana are not fully understood. If I am taking medication or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s). 10. Individuals may develop a tolerance to, and/or dependence on, marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I will contact Dr. JUNELLA CHIN or seek treatment with my primary care doctor. 11. Psychological signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness. 12. Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in the hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to immediately go to the nearest emergency room. 13. Pregnancy and breast-feeding: Marijuana is UNSAFE when taken by mouth or inhaled during pregnancy. Marijuana passes through the placenta and can slow the growth of the fetus. Marijuana use during pregnancy is also associated with childhood leukemia. Using marijuana, either by mouth or by inhalation is LIKELY UNSAFE during breast-feeding. The tetrahydrocannabinol (THC) in marijuana passes into breast milk. 14. If you subsequently learn that the information I have furnished is false or misleading, the recommendation for marijuana will no longer be valid and that the Department of Public Health will receive notice of this fraudulent behavior. I agree to promptly meet with you and/or provide additional information in the event of any inaccuracies or misstatements in the information I have provided. 15. I have had, or will have, the opportunity to discuss these matters with the physician and to ask questions regarding anything I may not understand or that I believe needed to be

8 clarified. I acknowledge that the physician has not provided a recommended treatment of my condition with medical marijuana. The physician did inform me of the risks, complications of any recommended treatment I choose to do on my own after obtaining the certificate. I acknowledge the physician has, informed me of any alternatives to medical marijuana that I may pursue with my primary care provider. 16. I agree not to transfer or sell my marijuana to anyone else and this will prosecuted to the fullest extent of the law. I also agree to not leave the state with my marijuana. 17. I must prevent children and adolescents from gaining access to medicinal cannabis because of potential harm to their well-being. I will store cannabis in locked cabinets to prevent anyone else from using it. 18. I know there is no legal precedent to help me if I am terminated from employment if a urine toxicology screen is positive for cannabis. 19. I know that some people cannot control their use of cannabis. One example is using cannabis for reasons other than for the indication for which it was prescribed; like getting stoned. This may lead to not going to work, or not doing my household chores. I agree to discuss this with my doctor if this happens. 20. I understand that this a trial treatment and may be temporary and not repeated if there is a better treatment that comes along. 21. The Prescription will be cancelled if I don t show up for appointments and avoid calls. Patient Signature:_ Date: Dr. Junella Chin Date:

9 Medical Records Release and Authorization For Use or Disclosure of Protected Health Information Please complete the following information: Patient Name: Address: Phone: SSN: Date of Birth: / / I authorize the custodian of records of: to disclose/release the following information* (Enter Name of physician or practice and Phone & Fax Number) Patient Chief Complaint For Records: (Enter Qualifying Condition) All records Laboratory/pathology records X-ray/radiology records Billing records Abstract/Summary Pharmacy/prescription records Office Notes Diagnosis and Treatments Including Med List Most Recent Physical Exam All dates These records are for services provided on the following date(s): 0-12 Months My specific authorization is necessary to release information pertaining to treatment and/or diagnosis of mental health conditions, substance abuse, and or HIV/AIDS status. I understand that I have the right to review any mental health information before release of such information. I authorize the release of potentially sensitive information. Mental Health (including anxiety and depression) Substance Abuse HIV/Aids Reason for Request: Consultation Transfer Of Care Please send the records listed above to Junella Chin, D.O. 75 SOUTH BROADWAY #423 WHITE PLAINS NY F: Name: Address: Phone Fax: This authorization shall expire 12 months from the date hereof unless an earlier date or event is stated here: I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information. When required, I authorize Junella Chin D.O. to discuss my case with the above provider. A copy of this authorization is available on request. Signature of patient (or patient s personal representative) Date Printed name of patient representative Representative s authority to Sign (parent, guardian, power of attorney for healthcare, executor) You have the right to revoke this authorization, except to the extent the custodian of records has relied on it, by sending your written request to the custodian of records listed above.!