CHEMICAL DEPENDENCY CLINIC

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CHEMICAL DEPENDENCY CLINIC 100 HIGHLANDS BLVD SUITE 101 PORT JEFFERSON NEW YORK 11777 631-331-8200 FAX 631-331-8259 Name: DOB: Address: City: Zip Code: Phone Numbers: Home: ( ) Can we call you at Home? Cell: ( ) Work: ( ) Can we call you at Work? Gender: MALE FEMALE Social Security #: Marital Status (circle one): Single Married Divorce Separated Widowed Living Together Race (circle one): American Indian or Alaska Native Black/African American Chinese Filipino Guamanian or Chamorro Hispanic White Japanese Korean Native Hawaiian Other Asian Other Pacific Islander Other Race Samoan Vietnamese White/Caucasian Undisclosed Ethnicity (circle one): Caucasian Afro-American Hispanic Asian Other Employer / School: Occupation: Primary Care Physician: Preferred Pharmacy: EMERGENCY CONTACT: Name: DOB: Address: City: Zip Code: PRIMARY INSURANCE: Insurance Plan: Policy Holder: Policy Holder DOB: Policy Number: Relation to Patient: Policy Holder SS#: SECONDARY INSURANCE: Insurance Plan: Policy Holder: Policy Holder DOB: Policy Number: Relation to Patient: Policy Holder SS#:

CHEMICAL DEPENDENCY CLINIC 100 HIGHLANDS BLVD SUITE 101 PORT JEFFERSON NEW YORK 11777 631-331-8200 FAX 631-331-8259 Patient Name: Date of Birth: Patient/Family Self-Reported Home Medication List Medical and Psychiatric Medications Please list below any medications that you are currently taking for medical and psychiatric illnesses, and the name of the practitioner who prescribes them. Please include any over the counter medications, herbal remedies or dietary supplements. Medication Dose Route Directions Prescriber Form Completed By: Date:

Page 1 of 5 Part A Doctor s Name: Address: Phone Number: Date of Last Exam: Dentist s Name: Address: Phone Number: Date of Last Exam: Has a Doctor EVER told you that you had any of the following conditions? Condition Check One w Past Currently Under a Doctor s Care Alzheimer s Disease or Dementia Blood Sugar-High Blood Pressure (High) Cancer Deafness or other hearing impairment Diabetes Endocrine Condition (High or Low thyroid, Pituitary or Adrenal Disease) Epilepsy/Seizures Heart Attack Hyperlipidemia (High blood fat/cholesterol and/or Trigycerides) Joint and connective tissue disease (Lupus, Rheumatoid arthritis, Osteoporosis, Osteoarthritis Kidney Disease Liver Disease ((Cirrhosis), Hepatitis A/B/C)) Mobility Impairment Other Cardiac Condition Progressive neurological condition (Multiple Sclerosis (MS), Cerebral palsy, Amyotrophic Lateral Sclerosis (ALS)) Pulmonary (Emphysema (Chronic Pulmonary Disease (COPD), Asthma) Sexually Transmitted or other Communicable Disease (for example, Herpes, Human Immunodeficiency Virus (HIV), History of active tuberculosis) Sight Impairment Speech Impairment Stroke Traumatic Brain Injury Weight (Obesity, Unexplained Gain or Loss) Other physical related health conditions Comment

Page 2 of 5 Medication Additional: CURRENT Medication Information ne (Include all current medication-psychiatric/n-psychiatric, Prescription/Over-the-counter drugs/herbal) Reason for Taking Dosage/Frequency and When taken (Dates/Length of time) Side-effects Helpful? Prescriber Medication HISTORY Information ne (As best as possible, list all additional medications taken for psychiatric or substance abuse issues in the past) Medication Reason for Taking Dosage/Frequency and When taken (Dates/Length of time) Additional - Are there any medications you would like to avoid taking in the future?: Side-effects Helpful? Prescriber Allergies/Drug Sensitivities ne Food (specify): Medicine (specify): Latex / Other (specify): Medical hospitalizations/significant operative and invasive procedures? If yes, complete information below: Hospital Date Reason Comments:

Nutrition/Hydration Screening Check if you have experienced: 1. Any weight loss or gain of 10 pounds or more in the past three months 2. Change in appetite 3. Are you experiencing any other problems eating or drinking? Pain Screening Page 3 of 5 The Joint Commission Do you have any ongoing pain problems? If yes, Medical Staff completes pain section below. For Women Only Currently pregnant? Receiving pre-natal healthcare? - If yes, expected delivery date: If yes, indicate provider: Are you currently breastfeeding? Any significant pregnancy history? If yes, explain: Menstruation Last menstrual Period Date: Menstrual Pain: Menstrual Irregularities: Other: Pre-menstrual symptoms: Polycystic Ovary Syndrome? If yes, Indicate provider: For Children Only Immunizations: Has the child or adolescent been immunized for the following diseases? Please check all that apply. Chicken Pox Diphtheria German Measles (rubella) Hepatitis B Measles Mumps Polio Small Pox Tetanus Other: All immunizations up to date? Comments: Prenatal exposure to Alcohol or other Drugs? Comments: Any other significant information that may affect care or place the child or adolescent at risk (for example, accidents or injuries): Completed By - Print Name: Signature: Date:

Page 4 of 5 Part B. Medical Assessment (To be completed by Medical Staff/Reviewer) Vital Signs/Physical Health Indicators (Required, Where Indicated, For PROS W/CLINIC & Vitals Required for COA Opioid and Strongly Recommended for Others) Blood Pressure: Abdominal girth: Temperature: Pulse: Respiration: Height: Weight: BMI: Nutritional/Hydration Status If individual answered yes to any of the items in Nutrition/Hydration Screening above, provide referral information below or rationale if no further action taken: Does individual have any medical concerns that may interfere with treatment or for which s/he needs assistance? If, explain: Pain Assessment Individual has pain based on Pain Screen section above: If yes, complete: Site #1 Site #2 Location: Location: Description: Pain is adequately controlled: Description: If no, is individual under medical care: - If no, make referral and document below: OASAS Actions Taken For those between the ages of 13 and 64: If HIV Test was negative, has the medical provider offered an HIV test? If no, explain: Did the undersigned check the Prescription Drug Monitoring Program (PDMP) for this individual? If no, provide reason: Physical Exam Information Physical Exam within the past 12 months; within 45 Days the individual will: Have a physical exam [Residential-Attach Copy]; or Have a face-to-face assessment by a medical staff member to determine the need for a physical exam [Outpatient-See Referral Section Below]; or OASAS Be referred for a physical examination [Outpatient-Complete Referral Information Below]. Physical Exam within the past 12 months or admitted directly to the service of another OASAS-certified service; the medical history and physical examination (including required laboratory tests) from such other services or physicians, (dated: ) has been reviewed and determined to be current and accurate by: clinical or medical staff member [Residential Signature & Credentials: Date: ]; or medical staff member [Outpatient Signature & Credentials: Date: ].

Page 5 of 5 The Joint Commission Was Last physical completed more than one year ago? - If, document referral below: OASAS Referrals and Recommendations Based on Face to Face Medical Assessment: Individual requires physical exam- see Individual does not require physical exam referral below, OR Nutrition/Hydration Referral: Pain Referral: Specialty Care: Primary Care Physician (General Referral): Primary Care Physician for Physical Exam and Date, if known: Other: Comments, if indicated: Completed By - Print Staff Name/Credentials: Staff Signature: Date:

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