Session Information Client: Ztest, Client (1615) Staff: Keller, Dianne (342) Document Date: 3/4/2016 Client Program: (Not Set) Focus of Treatment
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1 Session Information Client: Ztest, Client (1615) Staff: Keller, Dianne (342) Document Date: 3/4/2016 Client Program: (t Set) First Name: Last Name: Life domain(s) focuses of treatment: Problem 1 identified in requesting services/ interventions: Client Ztest DOB: 1/1/1985 Focus of Treatment Activities of Daily Living Financial Spirituality Social Supports Health Leisure / Recreation Vocational / Educational Problem 2 identified in requesting services/ interventions: Tools and talents identified that will be helpful in achieving goal(s): Identified familial and natural support strengths that may be used to make progress toward goal: Is Hope + Readiness = Action attached? Familial and Natural Supports (family harmony, culture/ethnicity, rituals, routines, socioeconomics and positive skills, lessons learned, and positive support people) Environmental and interpersonal stressors/ trauma: Environmental and interpersonal stressors/trauma that may impact progress towards goals or contribute to the DSM diagnosis If risk identified, please describe: Recommendations and referrals: Accepted? Legal factors: Legal Factors Legal factors that may impact ability to make progress towards goal or contribute Ztest, Client (1615) 1 of 18 Date Printed: 7/1/
2 to DSM diagnosis Recommendations and referrals: Accepted? Educational/vocational factors: Educational / Vocational Factors Educational/vocational factors that may impact progress towards goals or contribute to the DSM diagnosis Recommendations and referrals: Accepted? Concentration: Affect: Mood: Appearance: Motor Activity: Speech form and content: Hallucinations: Delusions: Memory: Current Mental Status Assessment Appropriate Intact Limited Recall Age/Culture Appropriate Constricted Age/Culture Appropriate Depressed Well-groomed Disheveled Calm Hyperactive rmal Slow ne Auditory ne Persecutory Intact Impaired - Immediate Erratic Labile Blunted Anxious Euphoric Bizarre Inappropriate Agitated Tremors Slurred Pressured Visual Olfactory Grandiose Religious Impaired - Recent Impaired Expansive Irritable Angry/Hostile Fair Tics Muscle Spasms Rapid Compound Other Judgment: Good Fair Poor Insight: Good Limited ne Orientation: Oriented x4 Impaired Person Impaired - Remote Ztest, Client (1615) 2 of 18 Date Printed: 7/1/
3 Suicidal*: Homicidal*: Self Injury: Verbal Aggression: Physical Aggression: Other: Place Time Context ne Plan Means Ideation Intent ne Plan Means Ideation Intent ne Plan Means Ideation Intent Hx ne Plan Means Threat Identified Target Hx ne Plan Means Threat Identified Target Hx If risk identified, please describe: Recommendations and referrals: Accepted? Symptoms Experienced or Observed Leading to DSM Diagnosis Symptom Experienced and Intensity: Frequency: Onset: Symptom Experienced and Intensity: Frequency: Onset: Symptom Experienced and Intensity: Frequency: Onset: Ztest, Client (1615) 3 of 18 Date Printed: 7/1/
4 Symptom Experienced and Intensity: Frequency: Onset: Symptom Experienced and Intensity: Frequency: Onset: Symptom Experienced and Intensity: Frequency: Onset: Psychiatric Hospitalizations: See Current Mental Status for additional symptoms Present health concerns: Health History Health care goals: When did you last see a doctor? When did you last see a dentist? When was your last eye exam? When did you last visit Urgent Care or the ER? Are there any medications you are taking that we don't know about? Include OTC or prescription medications Ztest, Client (1615) 4 of 18 Date Printed: 7/1/
5 Do you have any medication allergies? Do you have any of the following problems? Details of above or other problems: Personal Medical History Acid reflux (heartburn) Alcoholism / other addiction Allergies (environmental) Anxiety Asthma Atrial fibrillation COPD Cancer Cholesterol problem Chronic low back pain Coagulation (bleeding or clotting) problem Depression Diabetes mellitus Heart disease Hepatitis Hypertension (high blood pressure) Irritable bowel syndrome Kidney disease Migraines Osteopenia or Osteoporosis Thyroid problem Have you ever had any of the following problems? Describe: Cancer Heart attack Stroke (CVA) Blood transfusion Seizure Surgical history (list all prior operations and dates): Hospitalizations (other than surgery): Lipid test date: Lipid adnormal? Sigmoidoscopy test date: Sigmoidoscopy polyp? Colonoscopy date: Colonoscopy polyp? Prostate exam date: Prostate exam abnormal? Mammogram date: Mammogram abnormal? Health Maintenance Screening Tests Ztest, Client (1615) 5 of 18 Date Printed: 7/1/
6 Pap smear date: Pap smear abnormal? Bone density test date: Bone density abnormal? Total # of pregnancies: # births: # abortions: # miscarriages: First day of most recent period: Age at first period: Frequency of periods: Length of each: Any concerns about periods? Women's Health History If you have stopped have periods, when did you reach menopause? Any concerns about menopause? Hepatitis A: Hepatitis B: HPV: Tetanus (Td): Tetanus (TdaP): Measles: Mumps: Rubella: MMR: Meningitis: Shingles: Varicella (chicken pox): Pneumovax (Pneumonia): Other immunizations: Immunizations List of immunizations, with best estimate of the month and year for each. Alcoholism: Family History Ztest, Client (1615) 6 of 18 Date Printed: 7/1/
7 Anemia: Anesthesia problem: Arthritis: Asthma: Birth Defects: Bleeding Problem: Breast cancer: Colon cancer: Melanoma cancer: Other skin cancer: Ovarian cancer: Prostate cancer: Other cancer: Colon polyps: Diabetes Type 1 (child): Diabetes Type 2 (adult): Eczema: Epilepsy (seizures): Genetic diseases: Glaucoma: Hay fever (allergies): Hearing problems: Heart attack (CAD): Ztest, Client (1615) 7 of 18 Date Printed: 7/1/
8 High blood pressure: High cholesterol: Kidney diseases: Lupus (SLE): Mental retardation: Migraine headaches: Mitral valve prolapse: Osteoarthritis: Osteoporosis: Rheumatoid arthritis: Stroke (CVA): Thyroid disorders: Tuberculosis: Other: Tobacco use: When was the last time you smoked? Quit date: How many packs per day, for how many years? Other tobacco : Are you interested in quitting? I have never smoked I have smoked, but rarely Pipe Cigar Social History I have quit smoking I currently smoke cigarettes Snuff I use other tobacco Chew Do you drink alcohol? Never Occasionally Regularly Average number of 5 oz glasses of wine, 12 oz beers, 1.5 oz shots hard liquor Ztest, Client (1615) 8 of 18 Date Printed: 7/1/
9 drinks/week : Is alcohol use a concern for you or others? Do you use any recreational drugs? Have you ever used needles? Sexuality Sexually active: t currently Current sex partner(s) male female is/are: Birth control: ne needed Method: If sexually active, do you practice safe sex? Have you ever had any sexually transmitted diseases (STDs)? Type and date: Are you interested in being screened for sexually transmitted diseases? Other concerns? Do you use seatbelts consistently? If you ride a bike, do you use a bike helmet regularly? Is violence at home a concern for you? Are you currently in a relationship? Do you feel safe in this relationship? Do you have a gun in your home? Other concerns? Safety Ztest, Client (1615) 9 of 18 Date Printed: 7/1/
10 How active are you? I work out for 30 minutes 3 or more times/week Describe: I walk daily but do not work out Exercise I exercise or walk less than 3 times/week I am not generally active Other Oral hygiene: Personal Routine Shampoo/bathing: Sleep: What opportunity have you had for education? Travel history: Breasts: Constitutional: Ears/se/Throat/Mouth: Review of Symptoms Please mark any current problems you have: Breast pain/lump/ discharge Fevers/chills/sweats Problems with sleep Unexplained weight loss/gain Eyes: Change in vision Corrective lenses Difficult hearing Ringing in ears Problems with teeth/ gums Hay fever/allergies Respiratory: Cough/wheeze Difficulty breathing Fatigue/weakness Dentures Cardiovascular: Chest pain/discomfort Leg pain with exercise Palpitations Gastrointestinal: Abdominal pain Heartburn Bloody/black bowel movement Nausea/vomiting/diarrhea Blood/Lymphatic: Unexplained lumps Easy bruising/bleeding Genitourinary: Nighttime urination Leaking urine Painful or frequent urination Constipation Change in bowel habits Blood in urine Sexual function Ztest, Client (1615) 10 of 18 Date Printed: 7/1/
11 Musculoskeletal: Neurological: problems Muscle/joint pain or swelling Headaches Dizziness/light-headedness Numbness Memory loss Emotional: Anxiety/stress Depression Endocrine: Women only: Loss of coordination Skin: Rash Itching Mole change Prothesis: Excessive thirst or urination Pre-menstrual symptoms (bloating, cramps, irritablity Heat or cold sensitivity Problem with menstrual periods Hot flashes / night sweats Other: Alcohol: Use of Drugs and Alcohol Heroin: Sedatives: Tranquilizers: Amphetamines: Cocaine: Hallucinogens: Marijuana: Ztest, Client (1615) 11 of 18 Date Printed: 7/1/
12 Withdrawal Symptoms: Use Patterns: Problems Related to Substance Use and Level of Functioning Physical: Cognitive: Tolerance: Felt Need: Interpersonal problems: Aggression: Vocational: Legal: Financial: Treatment and Abstinence History: Family Substance Abuse Assessment: Stage of Change Ztest, Client (1615) 12 of 18 Date Printed: 7/1/
13 including treatment acceptance or resistance: Gambling behavior: Persons diagnosed with a gambling addiction, include the following: 1. Stage of change, including treatment acceptance or resistance 2. Cognitive/environmental conditions or complications 3. Relapse/Continued Use Potential Drug and Alcohol Assessment Summary Current Daily Structure: Education and Employment Education History: Military History: Ztest, Client (1615) 13 of 18 Date Printed: 7/1/
14 Employment History: Education and Employment Summary Social and Behavioral Development: Social Development and Functioning assess for the presence of physical or psychological trauma Natural Supports: include emergency contacts and next of kin Culture and Religious Beliefs: Leisure Activities: Ztest, Client (1615) 14 of 18 Date Printed: 7/1/
15 Social Skills: Legal Involvement: Social Development and Functioning Summary Living Arrangements: Activities of Daily Living Eating Habits/Food Preparation: Grocery Shopping: Diet and Exercise: Ztest, Client (1615) 15 of 18 Date Printed: 7/1/
16 Grooming: Laundry: Money Management: Housekeeping: Activities of Daily Living Summary Client DSM Diagnosis as of 7/1/ Client: Ztest, Client (1615) Effective Date/Time: 7/1/ External Diagnosis: Diagnosed By: Comments: Ztest, Client (1615) 16 of 18 Date Printed: 7/1/
17 DSM-5 ICD-10 Comments records found. Diagnosis The Diagnoses above display in priority order. ICD-10 Code - Description records found. Psychosocial and Contextual Factors Comments records found. Diagnostic Formulation Effective Date: 03/04/2016 Risk of Harm Level: Sub-Level Functional Status Level: Sub-Level Medical, Addictive, and Psychiatric Co- Morbidity: Sub-Level Recovery Environment Stress: Sub-Level Recovery Environment Support: Sub-Level Treatment and Recovery History: Sub-Level Engagement and Recovery Status: Sub-Level Level Total: Composite Score: LOCUS Recommended Level of Care: Assessor Recommended Level of Care: Assessment Clinical Formulation Ztest, Client (1615) 17 of 18 Date Printed: 7/1/
18 Enrollment is medically appropriate due to behaviors, thoughts, feelings, and symptoms independently complete the following tasks needed for accomplishing goal: impacting ability to communicate or process information needed to independently accomplish the following: effectively manage symptoms leading to the following behaviors jeopardizing independent living: successfully regulate mood or emotions leading to the following behaviors: Prognosis for reducing impact of symptoms on functioning to a level of demonstrating observable progress towards personal recovery goals: (as identified in strength's inventory) Validation Issues: Signatures Error: Requirements not met for Current Mental Status Assessment. Error: You must complete a Diagnosis or Psychosocial and Contextual Factor before this document can be signed. Error: You must complete a Diagnosis or Psychosocial and Contextual Factor before this document can be signed. Electronic Signature: The document can not be signed until the errors above are resolved. Signature History Action Date Staff records found Ztest, Client (1615) 18 of 18 Date Printed: 7/1/
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City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Do you currently have a family physician?: If not, where have you been getting health care?:
Adult Intake Form Preferred Location: Cambridge Kitchener Apply Patient Label here First Name: Last Name: Gender: Address: Phone number: Date of Birth: Health Card Number:_ Do you currently have a family
Thomas Balch ARNP Maurice Doerfler MD- Marybeth Lambe MD FAAFP
Thomas Balch ARNP Maurice Doerfler MD- Marybeth Lambe MD FAAFP Adult Health History We recognize you may have previously provided us with some of this information. We appreciate your cooperation in being
Please list current medications Include Herbal and over the counter medications Include dose and how many times a day drug is taken 1. 6.
Name Date Date of Birth Sex F M Allergies to Medications / Latex please include type of reaction Please list current medications Include Herbal and over the counter medications Include dose and how many
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:
Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire Please complete this questionnaire before your scheduled appointment and bring this form with you the day of your visit. Patient
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Personal Health Risk Appraisal
Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH 45434 Phone (937) 208-7000 Fax (937) 208-7010 Personal Health Risk Appraisal Last Name: First Name: MI:
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
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Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
Billings Clinic Urogynecology. Patient Name: Date of Birth: Visit Date:
Patient Name: Date of Birth: Visit Date: Please complete this questionnaire prior to arriving at the clinic so that we can be better prepared to address your particular health care needs. Provider who
Adult Health History Form Preferred Name: 1
Adult Health History Form Preferred Name: 1 Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are uncomfortable with
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
Reason for office visit today FOC Health History - ICM Health History Whom may we thank for referring you today? Do you have another primary care provider? Date of last physical exam Previous or referring
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation: