37 South 2 nd East, Rexburg, ID

Transcription

1 37 South 2 nd East, Rexburg, ID Patient Information Name: Date: Address: City: State: Zip Code: Telephone: Home: Cell: Birth date: Social Security Number: - - Marital Status: Married Widowed Divorced Single Sex: M F Employer: Primary Physician: Emergency Contact: Relationship to Patient: Emergency Contact Telephone: Address: (for medical use/lab results only) Responsible Party Party Responsible for Payment: Self Spouse Parent Other: Name (If different from patient): Birth Date: Address: City: State: Zip Code: Primary Insurance Primary Medical Insurance: Insured Party: Self Spouse Parent Other: ID# / Social Security Number: - - Group/Plan Number: Name (If different from patient): Birth Date: Address: City: State: Zip Code: Will you be applying for Medicaid? Yes No I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim. I assign the benefits payable to which I am entitled, including Medicaid, private insurance and other health plans, to Seasons Women s Center and authorize the practice to appeal on my behalf any incorrect insurance payment. This assignment will remain in effect until revoked by me in writing. I have also had the opportunity to review the Notice of Privacy statement, been provided an opportunity to ask questions, and understand I may request and review the Notice of Privacy statement at any time. Signature Date

2 Client Information Form Please complete this form as accurately as possible prior to you appointment. This will help to ensure that we have more time to discuss your current concerns. Thank you! Patient Name: Date of Birth: Name of Primary Care Doctor: Last Physical Exam: Past Medical History (please include all pre-existing & current medical conditions i.e asthma, heart conditions etc.): Past Surgical History (please include any previous surgeries & month/year): Past Psychiatric History (please include any psychiatric or substance abuse hospitalizations & diagnoses made by a psychiatric provider): Allergies & Sensitivities to Medications:

3 Client Information Form Current Medication List: Please include Over the Counter medications, Vitamins, Herbal supplements & Birth Control. Medication Name Dose Frequency Purpose of Mediation Any previously tried Psychiatric Medications: Mediation Name Dose Frequency Purpose of Medication Family Psychiatric History (please include known psychiatric diagnoses in blood related family members. Examples would be depression, anxiety, OCD, ADHD, bipolar disorder, eating disorder, and substance abuse disorder): Family Medical History (please include all significant medical illnesses):

4 SEASONS MEDICAL MENTAL WELLNESS Things to talk about today: Please check the symptoms that apply to this visit only GENERAL Fever Chills Sweats Fatigue Weakness Sleep disorder LUNGS Cough Shortness of breath Coughing up blood Chest discomfort Wheezing Excessive Sputum Snoring MUSCULOSKELETAL Muscle Cramps Joint pain Joint swelling Back pain Stiffness Muscle weakness Arthritis Gout Muscle aches PSYCHIATRIC Anxiety Suicidal thoughts Depression Hallucinations EYES Vision loss Double Vision Blurring Eye pain Halos Light sensitivity EARS/NOSE/THROAT Ringing in ears Earache Decreased hearing Nasal congestion Nose bleeds Difficult swallowing Hoarseness Sore throat HEART Difficulty breathing at night Chest pain Racing heart beat Lightheaded Shortness of breath Palpitations Swelling of hands and feet Difficulty breathing when laying down Leg cramps Weight gain BOWELS Excessive appetite Loss of appetite Indigestion Nausea Vomiting Gas Abdominal pain Abdominal bloating Hemorrhoids Diarrhea Change in bowel habits Constipation Blood in stools GENITAL/URINARY Foul urinary discharge Blood in urine Urinary frequency Inability to empty bladder Urinary urgency Kidney pain Trouble starting urination Painful urination Nighttime urination Inability to control bladder Lack of sex drive Pelvic pain Erectile dysfunction SKIN Night sweats Dryness Poor wound healing Itching Flushing Rash NEUROLGICAL Difficulty concentrating Poor balance Headaches Numbness Falling Down Tingling Brief paralysis Seizures Tremors Fainting Excessive daytime sleeping Memory loss Dizziness ENDO Excessive hunger Cold intolerance Heat intolerance Excessive urination Excessive thirst Weight change BLOOD/LYMPH Enlarged lymph nodes Abnormal bruising ALLERGIES Persistent infections Rashes/hives Seasonal allergies

5 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Adult Name: Age: Sex: Male Female Date: If this questionnaire is completed by an informant, what is your relationship with the individual? In a typical week, approximately how much time do you spend with the individual? hours/week Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days I. 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? II. 3. Feeling more irritated, grouchy, or angry than usual? III. 4. Sleeping less than usual, but still have a lot of energy? Severe Nearly every day Highest Domain Score (clinician) 5. Starting lots more projects than usual or doing more risky things than usual? IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 7. Feeling panic or being frightened? 8. Avoiding situations that make you anxious? V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 10. Feeling that your illnesses are not being taken seriously enough? VI. 11. Thoughts of actually hurting yourself? VII. 12. Hearing things other people couldn t hear, such as voices even when no one was around? 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? VIII. 14. Problems with sleep that affected your sleep quality over all? IX. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? XI. 17. Feeling driven to perform certain behaviors or mental acts over and over again? 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? XII. 19. Not knowing who you really are or what you want out of life? 20. Not feeling close to other people or enjoying your relationships with them? XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? Copyright 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.