1 Patient Registration Form Date: Patient Name: Social Security #: Date of Birth: Age: Billing Address: City: State: Zip Code: Home Address City: State: Zip Code: Home Phone#: Cell #: Work #: Email Address: Who referred you to the office? Family Doctor: Phone #: Emergency Contact: Phone #: Primary Insurance: ID #: Insured s Name: Date of Birth: Riverview Psychiatric Medicine, PC
2 Office Policy **Please read and sign the following information concerning the policies of the office. A Copy of these policies will be available upon request** Authorization: I, (your name), hereby authorize Riverview Psychiatric Medicine, PC as needed and/or requested: To release any applicable mental health information to my primary care physician (PCP) named above on page 1. To release any applicable substance abuse information to my PCP named above on page 1. Not to release any information to my PCP named above on page 1. I may revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization it will expire in one (1) year after I have terminated treatment. I have read and understand this statement: Insurance Payment Order (Except Patients of Dr. Pardell or self-pay patients) I, (your name), hereby authorize my insurance company to pay directly to Riverview Psychiatric Medicine, PC all benefits due to me. This policy was in full force an effective at time of treatment. I understand that I am financially responsible for all balances remaining after payment of possible insurance benefits, and that, should it become necessary, any and all reasonable collections and attorney fees will be added to my bill. I also understand that my health information and records will be used, as needed, to obtain payment for my health care services from my insurance providers. This may include certain activities the Riverview Psychiatric Medicine, PC staff may need to undertake before my health care insurer approves or pays for health care services recommended for me, such as determining eligibility of coverage for benefits, reviewing services provided to me for medical necessity, and undertaking utilization review activities. I have read and understand this statement: Forms: If you require legal, financial, or insurance forms to be completed by a Riverview clinician, it will need to be done in a scheduled session otherwise you will be charged and billed for the time that clinicians take to fill out the requested documents. I have read and understand this statement:
3 Riverview Psychiatric Medicine, PC Payment Policy You are responsible for all co-payments and/or fees at the time of service, otherwise billing fees will be incurred. If another party is responsible for your payments, please let us know prior to your visit so that we may make the necessary arrangements. A fee of $45.00 will be charged for any return checks, along with a processing fee. I have read and understand this statement: Cancellation Policy Any cancellations and/or rescheduling of appointments MUST be done at least 24 hours in advance. Patients who cancel the day of an appointment or do not show for their appointment will be responsible for the full session fee (not just the co-pay). Monday appointments must be canceled by noon of the preceding Friday. **Appointment reminders/ confirmation calls are done as a courtesy** I have read and understand the statement: (Signature of patient or guardian) Informed Consent for Treatment I, (your name) agree and consent to participation in the health care services offered and provided by Riverview Psychiatric Medicine, PC, a health care facility. I understand that I am consenting and agreeing only to those services that the above provider is qualified to provide within (1) the scope of the license, certification, and training of the health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen (18) or unable to consent to treatment, I attest that I have legal custody of this individual and am legally authorized to initiate and consent to treatment on behalf of this individual. I have read and understand the statement: (Signature of patient or guardian) Medicare/Medicare HMO Dr. Randy Pardell, Terri Coonrad-Hershkowitz, and Dr. Kenneth Wilson have opted out of Medicare. If you are a Medicare patient, neither you nor our office by law can submit for any reimbursement. Please ask the front desk for an opt-out form. I have read and understand the statement:
Adverse Reaction History of use Current Use Not Helpful Helpful 4 Riverview Psychiatric Medicine, PC MEDICATION QUESTIONNAIRE Directions: Please complete this questionnaire to the best of your recollection. Generic Name Trade Name Patient, Parent, Guardian or Provider comments ANTIDEPRESSANTS Fluoxetine Paroxetine Sertraline Fluvoxamine Citalopram Escitalopram Desipramine Imipramine Doxepin Clomipramine Nortriptyline Bupropion Venlafaxine Duloxetine Nefazodone Mirtazapine Trazodone Selegiline Transdermal Prozac Paxil, Paxil CR Zoloft Luvox, Luvox CR Celexa Lexapro Norpramin Tofranil Sinequan Anafranil Pamelor Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban Effexor, Effexor XR Cymbalta Serzone Remeron, Remeron Sol Tab Desyrel Emsam Desvenlafaxine Pristiq Phenelzine Nardil Tranylcypromine Parnate Vortioxetine Trintellix Levomilnacipran Fetzima Vilazodone Viibryd ANTIPSYCHOTICS major tranquilizers Thioridazine Mellaril Paliperidone Invega Chlorpromazine Thorazine Thiothixene Navane Haloperidol Haldol, Haldol Decanoate Perphenazine Trilafon Loxapine Loxitane Trifluoperazine Stelazine Fluphenazine Prolixin, Prolixin Decanoate Clozapine Clozaril Olanzapine Zyprexa, Zyprexa Zydis Quatrain Seroquel, Seroquel XR Risperidone Risperdal, Risperdal Consta Cariprazine Vraylar Rexulti Brexpiprazole
Adverse Reaction History of use Current Use Not Helpful Helpful 5 Generic Name Trade Name Patient, Parent, Guardian or Provider comments Aripiprazole Cariprazine Ziprasidone ANXIOLYTICS antianxiety minor tranquilizers Alprazolam Diazepam Chlordiazepoxide Buspirone Lorazepam Clonazepam hydroxyzine ANTICHOLINESTERASE/ ALZHEIMER S AGENTS Tacrine Donepezil Rivastigmine Memantine ALCOHOL/DRUG/SMO KING CESSATION AGENTS Acamprosate Methadone Naltrexone Disulfiram Buprenorphine/ Naloxone Abilify Vraylar Geodon Xanax, Xanax XR Valium Librium BuSpar Ativan Klonopin, Klonopin Wafers Vistaril, Atarax Cognex Aricept Exelon Namenda Campral Dolophine ReVia Antabuse Suboxone/Subutex Varenicline MOOD STABILIZING AGENTS/AED s Carbamazepine Oxcarbazepine Valproate Lamotrigine Gabapentin Topiramate Levetiracetam Olanzapine Lithium PSYCHOSTIMULANTS Methylphenidate Methylphenidate Transdermal Amphetamine, Dexotroamphetamine Chantix Tegretol Trileptal Depakene, Depakote, Depakote ER Lamictal, Lamictal XR Neurontin Topamax Keppra Zyprexa, Zyprexa Zydis Eskalith, Eskalith CR, Lithobid Ritalin, Ritalin SR, Ritalin LA, Concerta, Metadate ER/CD Daytrana Adderall, Adderall XR
Adverse Reaction History of use Current Use Not Helpful Helpful 6 Generic Name Trade Name Patient, Parent, Guardian or Provider comments Dexmethylphenidate Dextroamphetamine Lisdexamfetamine dimesylate Modafinil Armodafinil Guanfacine Clonidine Focalin, Focalin XR Dexedrine, Dextrostat Vyvanse Provigil Nuvigil Intuniv, Tenex Catapres
7 Medical & Psychiatric History This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability. Yes No 1. Are you in good physical health? 2. Has there been any change in your general physical health in the last year? 3. Date of your last physical examination (on or about) 4. Have you ever had any serious illness or operation? If so please explain: 5. Are you currently under the care of a physician for any physical condition? 6. Are you taking any prescription drugs or medications at the present time? If so please list: Name of Medication Strength in MG Date Began Reason for Taking
8 Are you taking any non-prescription drugs, including natural remedies and vitamins? Yes No If so please explain: Name of Medication Strength in MG Date Began Reason for Taking Are you aware of or has a physician ever told you of any allergies/adverse reactions Yes No to any medications or drugs? If so please explain: Name of Medication Reaction
9 Yes No Have you ever been hospitalized? If yes, please list and explain Reason Date of Hospitalization Location (city & state) Treatment Received Do you have any of the following problems? Yes No Yes No Cancer Rheumatic Fever Lupus or Autoimmune Disorder Arthritis or Rheumatism Chronic Pain or Complex Regional Pain Disc Disease Stomach Ulcer Gastroesophageal Reflux Irritable Bowel Syndrome Colitis Liver Disease Hepatitis or Jaundice Cardiovascular Disease or Heart Failure Heart Attack/Myocardial Infarction High Blood Pressure Coronary Artery Disease/Arteriosclerosis Diabetes/ High Blood Sugar Under Active Thyroid Overactive Thyroid Anemia Blood Clotting Problems Tuberculosis Asthma Hay Fever or Seasonal Allergies Hives or Skin Rashes Venereal Disease/STD Sexual or Erectile Dysfunction Bladder Problems Kidney Disease/Kidney Stones Migraine/Cluster/Tension Headaches Fainting Spells Seizures or Convulsions Parkinson s Disease Dementia or Alzheimer s Disease Glaucoma or Macular Degeneration Fibromyalgia Lyme Disease, Babesia, Ehrlichea Other(explain) Do you have any physical disease or condition not listed above that you think the doctors should know about?
10 Mental Health Questionnaire 1. In chronological order, please list all psychiatrist and/or psychotherapists (psychologists, nurse practitioners, certified social workers, counselors, etc) who have attended you beginning with the most recent: Name Profession/Title Treatment (therapy, meds, ect) Date started Date Ended Reason Discontinued Yes No 2. During the last four (4) weeks, have you been bothered by any of the following? Stomach Pain Back Pain Pain in your arms, legs or joints Menstrual cramps, or problems with your period Headaches Chest Pains Dizziness Fainting spell Feeling your heart pound or race Shortness of breath Constipation Loose bowel or diarrhea Nausea, gas, or indigestion
11 Yes No 3. Over the last two (2) weeks, have you been bothered by any of the following? Little to no interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling asleep or staying asleep Sleeping too much Feeling tired or having little energy Poor appetite or over-eating Feeling bad about yourself Feeling that you are a failure or have let others down Trouble concentrating on things such as reading, watching TV Moving or speaking slowly that other people have noticed Being so fidgety or restless that other people have noticed Thoughts that you would be better off dead or hurting yourself Persistently elevated, expansive mood (manic) Inflated self-esteem Pressured to keep talking Racing thoughts Distractibility (including being diagnosed with ADD or ADHD) Impulsiveness (buying sprees, sexual indiscretions, foolish investments) Hallucinations (Auditory, visual symptoms that others do not see) Paranoia (Believing that others are out to hurt or harm you) Yes No 4. Questions about anxiety In the last four (4) weeks have you had an anxiety attack? (Suddenly feeling fear or panic) **If you checked no, go to question 6** Has this ever happened before? Do some of these attacks come suddenly out of the blue or in situations Where you don t expect to be nervous or uncomfortable? Do these attacks bother you a lot or are you worried about having another?
12 5. Think about your last bad anxiety attack: Yes No Were you short of breath? Did your heart race? Did you have chest pain or pressure? Did you sweat? Did you feel as if you were choking? Did you have hot flashes or chills? Did you have nausea or an upset stomach, or the feeling that you were going to have diarrhea? Did you feel dizzy, unsteady or faint? Did you tremble or shake? Were you afraid you were dying? Yes No 6. Over the last four (4) weeks have you been bothered by the following problems? Feeling nervous, on edge or worried a lot about different things? **If you checked no, go to question 7** Feeling restless so that it is hard to sit still Getting tired very easily Muscle tension, aches or soreness Trouble falling asleep or staying asleep Trouble concentrating on things such as reading, watching TV Obsessions (fear of contaminations, intrusive thoughts of harm, need for order or symmetry) Becoming easily annoyed or irritated Compulsions (checking doors, oven, washing hands) Social anxiety (center of attention, avoiding social situations) 7. Questions about eating: Yes No Do you often feel that you can t control what or how much you eat? Do you often eat within any 2 hour period what most people would regard as an unusually large amount of food? Do you fear gaining weight or feel fat? Do you frequently diet or restrict your caloric intake? (<1000 cal/d) **If you answered no, go to question 9**
13 8. In the last three (3) months, have you often done any of the following to avoid Yes No gaining weight? Made you vomit Taken more than twice the recommended dose of laxatives Fasted (not eaten anything at all for at least 24 hours) Exercised for more than an hour, specifically to avoid gaining weight after binge eating If you checked YES to any one of these ways of avoiding gaining weight, were any as often or average of twice a week? 9. Do you ever drink alcohol, including beer and wine? **If you answered no, go to question 11** 10. Have any of the following happened to you more than once in the last six (6) months? You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health You drank alcohol, were intoxicated from alcohol, or were hung over while you were working, going to school, or taking care of someone else s children or other responsibilities. You missed or were late for work, school or other activities because you were drinking or hung over You had problems getting along with others while drinking You drove a car after having several drinks or drinking too much alcohol Yes No 11. Do you presently use recreational drugs? If yes, please give details: 12. Have you ever used alcohol or drugs more than you do now? If yes, please explain to what extent
14 13. In the last four (4) weeks have you been bothered by any of the following problems? Yes Worrying about your health Your weight or how you look Little or no sexual desire or pleasure during sex Difficulties with your husband/wife or significant other The stress of taking care of children, parents or family Stress at work, outside of the home or school Financial problems or worries Having no one to turn to when you have a problem Something bad that happened recently Thinking or dreaming about something terrible that happened to you in the past (like your house being destroyed, a severe accident, being physically, mentally or sexually abused), PTSD symptoms Learning disability (Dyslexia, ADHD, Math Disability) Have you experienced an unusual sensitivity to common noises such as someone eating, tapping on a computer, pen clicking, breathing, coughing, or hiccupping. No 14. In the last year have you been hit, slapped, kicked, or otherwise physically hurt by someone, or has anyone forced you to have unwanted sexual acts? 15. What is the most stressful thing in your life right now? 16. If you checked off any of the problems on the questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? a. Not difficult at all c. Very difficult b. Somewhat difficult d. Extremely difficult Yes No 17. Has anyone in your family ever suffered from any psychiatric disorder? (i.e. Bi-polar, manic depression, anxiety disorder, schizophrenia, ADHD or alcohol or substance abuse) If yes please explain:
15 For Women Only 18. Which best describes your menstrual period? (circle) a. Periods are unchanged b. No period because of pregnancy or recently given birth c. Periods have become irregular or changed in frequency, duration, or amount d. No periods for at least one (1) year (Menopause) e. Having no periods because taking hormone replacement or contraceptive 19. During the week before your period starts, do you have a serious problem Yes No with your mood, like depression, anxiety, irritability, anger or mood swings? 20. Pregnancy: a. Have you given birth within the last six (6) months? b. Have you had a miscarriage within the last six (6) months? c. Are you having difficulty getting pregnant? 21. Perimenopausal Symptoms: a. Have you had hot flashes b. Have you had vaginal dryness and/or painful intercourse? c. Have you experienced irregular periods, mood instability, anxiety, or depression? d. Have you been prescribed hormone therapy? e. Have you had a change in your libido or sexual interest? For Men Only 22. Erectile or Sexual Dysfunction: a. Have you ever had difficulty maintaining an erection? b. Have you had a change in your libido or sexual interest? c. Have you ever been treated for Erectile Dyfunction? d. Have you ever been prescribed Viagra, Cialis or Levitra? e. Have you ever been treated for low testosterone? f. Have you ever been treated for Peyronie s Disease?