The ADHD Center of New England/Jeffrey Wishik, M.D./Brain Mapping & Computerized Neurophysiology Laboratory, Inc.

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1 The ADHD Center of New England/Jeffrey Wishik, M.D./Brain Mapping & Computerized Neurophysiology Laboratory, Inc. Patient Information Form Patient Name: Date of Birth: Address City State Zip Home # ( ) Cell # ( ) Work # ( ) Marital Status: S M D W address: Emergency Contact: Phone( ) PRIMARY INSURANCE (Insurance companies require this information for billing purposes.) Name of Insured: Relationship to Pt: Insurance Company: Insured s DOB: / / Insured s Phone:( ) SECONDARY INSURANCE Name of Insured: Relationship to Pt: Insurance Company: Insured s DOB: / / Insured s Phone:( ) To the extent permitted by law, I hereby authorize the release of any information concerning the services rendered that is necessary to process any insurance claims. I also hereby authorize payment of insurance benefits to the Brain Mapping & Computerized Neurophysiology Laboratory Inc., and Jeffrey Wishik, M.D., for services they bill to my insurer as participating providers. I understand that I am responsible to pay for any copayments at the time of service. I understand that I am responsible to pay any deductibles, co-insurance, or any other allowable charges within 30 days of the insurer s denial/determination of benefits or at my next scheduled visit whichever is sooner. If I do not have insurance or if the Brain Mapping & Computerized Neurophysiology Laboratory Inc., and Jeffrey Wishik, M.D., are not providers of my insurance or are providing uncovered services, I understand that I am responsible for payment of fees for all services provided at time of service. Signature of patient, parent, or legal guardian (circle one) Date Page 1 of 15

2 GENERAL INSTRUCTIONS FOR COMPLETING THE FORMS In order to process the request for your Quotient testing at our office, we must ask you to complete the enclosed information forms. Your answers will give us a much better understanding of your behavior and symptoms. Please follow these instructions as closely as possible: 1. All forms in this packet should be completed. Please do not staple the forms. 2. If you are already taking medication for ADD/ADHD (such as Ritalin, Concerta, Focalin, Vyvanse, or Adderall) or for any psychological conditions such as depression, complete the screening tests about your behavior based on how you behave when you are OFF this medication. This way, we can get a clearer idea of the true nature of your difficulties without the changes produced by any medication. If you are unable to give us this information, please check the third blank line below to indicate that you based your answers on your behavior when you are taking medication. Check one of the blanks below to let us know for certain how you judged your behavior in answering these forms: I do NOT take any medication for behavior problems. I am CURRENTLY TAKING MEDICATION for behavior problems, but my answers are based on my behavior while OFF medication. I am CURRENTLY TAKING MEDICATION for behavior problems and my answers are based on my behavior while ON medication. Finally, please list medications you are taking for any behavioral/emotional issues or psychological conditions: Thank you for completing these screening forms. PLEASES REMEMBER TO BRING ALL COMPLETED FORMS TO THE TEST. WE CANNOT INTERPRET THE TEST WITHOUT THE INFORMATION IN THESE FORMS. Page 2 of 15

3 ADULT SYMPTOMS NAME DATE INSTRUCTIONS: Please circle the number next to each item that best describes your behavior during the past 6 months. Item Fail to give close attention to details or make careless mistakes in my work Never or Rarely Sometimes Very Fidget with hands/feet or squirm in seat Have trouble sustaining my attention in tasks or fun activities Leave my seat when sitting is expected Don t listen when spoken to directly Feel restless Don t follow through with instructions and fail to finish work Have trouble engaging in leisure activities or doing fun things quietly Have trouble organizing tasks and activities Feel on the go or driven by a motor Avoid, dislike, or am reluctant to engage in work that requires sustained mental effort Talk excessively Lose things necessary for tasks and activities Blurt out answers before questions have been completed Am easily distracted Have difficulty awaiting my turn Am forgetful in daily activities Interrupt or intrude on others How old were you when these problems started? years old Page 3 of 15

4 To what extent do the problems you may have circled on the previous page interfere with your ability to function in each of these areas of life activities? Area Never or Rarely In my home life with immediate family In my work or occupation In my social interactions with others In my activities in the community In any educational activities In my dating or marital relationship In my management of my finances In my driving of a motor vehicle In my leisure or recreational activities In my management of my daily responsibilities Very Again, please circle the number next to each item below that best describes your behavior during the past six months. Area Never or Rarely Sometimes Sometimes Lose temper Argue Very Actively defy or refuse to comply with rules or requests Deliberately annoy people Blame others for my mistakes or misbehavior Am touchy or easily annoyed by others Am angry or resentful Am spiteful or vindictive Page 4 of 15

5 General Health History Have you ever had any of the following problems? If yes, place a mark to show when. Allergies/Asthma Problem During Childhood Past (as an adult) Now Heart disease Epilepsy or Seizures High blood pressure Serious head or brain injury Injury causing loss of consciousness Lead poisoning Broken bones Surgery Migraines Thyroid disease (under- or overactive) Vision loss Hearing loss Diabetes Other serious illness Explain: Are you taking any medications currently? Yes No If yes, please name them: Describe any other health difficulties you have experienced or are currently experiencing: Page 5 of 15

6 Employment History What is your current employment status? (Circle one) Full time Unemployed Homemaker Part time Student Disabled If employed, what is your occupation? Who is your employer? How long have you worked at your present job? Please list your jobs since completing your education: Title Years on Job Reason for Leaving What is your longest period of employment at one place? Have you ever been fired from a job? Yes No If yes, how many jobs were you fired from or asked to leave? Have you served in the military? Yes No If yes, please give details: Briefly describe the types of problems you have had in the workplace, either now or in the past: Page 6 of 15

7 Social History How would you describe your mood most of the time? (Circle one) Cheerful/happy Sad/depressed Changes all the time Anxious/nervous Angry/irritable Bland/unfeeling Do your moods change frequently, abruptly, and/or unpredictably? Yes No If yes, give details: Do you have trouble making friends? Yes No Do you have trouble keeping friends? Yes No Do you have trouble in your relationships with others? Yes No If yes, give details: Do you have problems with your temper? Yes No If yes, give details: Do you have a driver s license? Yes No Has your license ever been limited, suspended, or revoked? Yes No If yes, give details: How many speeding tickets have you gotten? Have you ever been stopped for driving while intoxicated or impaired? Yes No How many auto accidents have you been involved in, regardless of fault? How many times did your family move when you were a child and teenager? How many times have you moved since leaving high school? If you believe you have ADD/ADHD, describe how it interferes with your life: How have you tried to compensate for or cope with your deficits? Page 7 of 15

8 Developmental History Were there any problems with your mother s pregnancy with you? Yes No If yes, please give details: Were there any problems associated with your birth? Yes No If yes, please give details: Did your mother use alcohol or other drugs during the pregnancy? Yes No If yes, please give details: Did your mother smoke cigarettes during the pregnancy? Yes No If yes, please give details: Did you have any significant delays in your development? Yes No (Sitting up, walking, talking, etc.) If yes, please give details: Did you have any serious childhood illnesses/diseases/surgeries? Yes No If yes, please give details: Did you have any problems getting along with other children? Yes No If yes, please give details: Page 8 of 15

9 Circle any of the following traits/behaviors you believe you had as a child: Defiant Aggressive Stubborn Destructive Hyperactive Impulsive Inattentive Distractible Shy Withdrawn Depressed Anxious Fearful Lying Stealing Fighting Circle any of the following areas where you had trouble as a child: Learning Language Memory Motor skills Sleeping Eating Toilet training If you experienced strange ideas during childhood please explain: If you exhibited strange behavior during childhood pleas explain: Page 9 of 15

10 Childhood Behavior Symptoms INSTRUCTIONS: Please circle the number next to each item below that best describes your behavior when you were between 5 and 12 years old. Item Failed to give close attention to details or made careless mistakes in my work Never or Rarely Sometimes Very Fidgeted with hands/feet or squirm in seat Had trouble sustaining my attention in tasks or fun activities Left my seat in classroom or in other situations when sitting was expected Didn t listen when spoken to directly Felt restless Didn t follow through with instructions and failed to finish work Had trouble engaging in leisure activities or doing fun things quietly Had trouble organizing tasks and activities Felt on the go or driven by a motor Avoided, disliked, or was reluctant to engage in work that requires sustained mental effort Talked excessively Lost things necessary for tasks and activities Blurted out answers before questions were completed Was easily distracted Had trouble waiting my turn Was forgetful in daily activities Interrupted or intruded on others Page 10 of 15

11 When you were a child between 5 and 12 years old, to what extent did the problems you circled on the previous page interfere with your ability to function in each of the following areas of life? Area Never or Rarely In my home life with my immediate family In my social interactions with other children In my activities or dealings in the community In school In sports, clubs, or other organizations In learning to take care of myself In my play, leisure, or recreational activities Very In my handling of daily chores or other responsibilities Please circle the number next to each item below that best describes your behavior when you were between 5 and 12 years old. Area Never or Rarely Sometimes Sometimes Lost temper Argued with adults Very Actively defied or refused to comply with rules or adults requests Deliberately annoyed people Blamed others for my mistakes or misbehavior Was touchy or easily annoyed by others Was angry or resentful Was spiteful or vindictive Page 11 of 15

12 Please indicate whether you engaged in any of the following behaviors or activities when you were between 5 and 18 years old. bullied, threatened, or intimidated others Yes No initiated physical fights Yes No Used a weapon that could cause serious physical harm to others Yes No Was physically cruel to people Yes No Was physically cruel to animals Yes No Stole while confronting a victim (e.g. mugging, purse snatching) Yes No Forced someone into sexual activity Yes No Deliberately set a fire with the intention to cause serious damage Yes No Deliberately destroyed others property (other than by fire) Yes No Broke into someone else s home, building, or car Yes No lied to obtain goods or favors, or to avoid obligations Yes No Stole items of nontrivial value without confronting a victim Yes No (e.g. shoplifting, forgery) stayed out at night despite parental prohibitions Yes No If yes, at what age did this begin? Ran away from home overnight at least twice while living in parents home, foster care, or group home Yes No If yes, how many times? Was often truant from school Yes No If yes, at what age did this begin? Page 12 of 15

13 OFFICE POLICIES APPOINTMENTS & PAYMENTS We reserve specific appointment times for you and do not "double book" patients. If you must cancel an appointment we need at least 24 hours notice. We try to leave reminders about your scheduled visit but this is not always possible. If we do not call or , you are still responsible to keep your appointment - even if you have ADHD. If you miss a follow-up visit or do not cancel 24 hours in advance you will be billed $75 for each appointment. Your insurance will not cover this fee. If this happens repeatedly we will discharge you from the practice. These policies are necessary because of the large number of people waiting for openings. Missed appointments waste time that someone else could have used and interfere with our ability to monitor your condition appropriately - especially important if you are taking a stimulant medication. The government expects us to monitor our patients on a regular basis. Monitoring may include drug testing for all patients taking stimulants. Your co-payments or any other fees not covered by insurance are due at the time of service. Charges not covered by your insurer must be paid within 30 days of the insurer's denial/benefits determination. You are required to present your insurance card(s) at every visit. If your plan requires a referral from your primary care physician please obtain it before your visit. We accept Visa, MasterCard, American Express, Discover, cash, and personal checks. STIMULANT PRESCRIPTION REFILLS Stimulant prescriptions are only written during regular office hours. Call our refill line or send an e- mail at least one day before you need your refill. If you want it mailed, provide us with selfaddressed, stamped envelopes and tell us to mail it. Otherwise, you need to come here for the prescription because we cannot fax or phone these to the pharmacy. We do not call to let you know when your prescription is ready. If there are no problems your prescription(s) will be available after 1 PM, the first working day after you make your request - not the same day. Note: For early refill requests we reserve the right to request travel documents or a police report (for stolen medication). Repeated early refill requests or lost prescriptions/medications are grounds for discharge. We will not prescribe stimulant medications if you obtain these medications from other sources. We reserve the right to perform random drug testing. If you miss your appointment we will not refill your stimulant prescription. Page 13 of 15

14 Jeffrey Wishik, MD, JD Jennifer Walden, RN, MSN, ANP The ADHD Center of New England Brain Mapping & Computerized Neurophysiology Laboratory, Inc. RECEIPT OF HIPAA PRIVACY NOTICE and NOTICE OF OFFICE POLICIES ACKNOWLEDGEMENT FORM I,, am aware of and understand this practice s HIPAA Privacy Notice (available on this website) and Office Policies (previous page). Signature of Patient or Legal Guardian Date Page 14 of 15

15 Acknowledgement and Consent Dr. Wishik and The ADHD Center of New England (aka Brain Mapping & Computerized Neurophysiology Laboratory) will bill for the Quotient study using neuropsychological testing codes and Some insurance plans require a referral or prior authorization for this testing and have a deadline for submission of this information. I understand that I am responsible for payment if I do not provide the necessary referral or prior authorization. I acknowledge that I am responsible for payment of any copayments, coinsurance, or unmet deductibles. Furthermore, should my insurer determine for any reason that this testing is not covered or reimbursable, I am responsible for payment of the Quotient testing fee. Signature Date If signing for a minor, your relationship Page 15 of 15

BDS-2 QUICK SCORE SCHOOL VERION PROFILE SAMPLE

BDS-2 QUICK SCORE SCHOOL VERION PROFILE SAMPLE BEHAVIOR DIMENSIONS SCALE-2 Name of student: Andrea Thomas School: Midvale High School Class: Science City: Midvale SCHOOL VERSION RATING FORM PROFILE SHEET Gender: Female Grade: State: NY Subscales SUMMARY