Client Information - Enhanced

Wellness Nashville Client Info

Enhanced - ver: 10/25/2021
Information Sheet
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Email:*

Confirmation Emailexample@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number:*
Preferred Phone:*
Please enter a valid phone number.
Alternate Phone:
Please enter a valid phone number.
If unable to reach me:

you may leave a detailed messageyou may leave a message asking me to return your callyou may text meyou may email me
The best time to reach me is day between time.
Do you wish to receive info, promos, and discounts?*

Yes, please sign me up.No thanks.
Emergency Contact
Name:

First NameLast Name
Relationship:
Is contact address the same as above?

YesNo
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Who referred you to us?*

Advertisement (Please specify media type)Another Client (Please specify)Business or Business associate (Please specify)Clergy or Church member (Please specify)Counselor or MH program (Please specify)EmailFlyerFriend or Acquaintance (Please specify)InternetOtherNone
Please describe:
Insurance
Do you have medical insurance?

YesNo
We now work with most major insurance providers.
Primary Provider:

BCBSAetnaCignaUnited HealthcareOther
Group Policy #:
Individual Policy #:
Secondary Provider:

BCBSAetnaCignaUnited HealthcareOther
Group Policy #:
Individual Policy #:
Gender:

MaleFemale
Current living situation:

MarriedSingleDivorcedWidowedLegally Separated
Do you have children living with you?

YesNo
How Many?
Ages?
Are you currently employed?

YesNo
Occupation:
What is your main goal in getting NAD therapy?
Do you have a history of heart failure?

YesNo
Do you have a history of cancer?

YesNo
What type?
Dates of care:
Last Physical Exam:
By Whom:
Last Mammogram:
Last Colonoscopy:
Height - feet:
Height - inches:
Weight - pounds:
BMI (office use only):
Rank stress over last 3 months:

1=Low2345678910=High
Activity level:

Inactive: no regular physical activity with a sit-down jobLight activity: no organized physical activity during leisure timeModerate activity: occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cyclingHeavy activity: consistent lifting, stair climbing, heavy construction, etc. or regular participation in jogging, swimming, cycling or active sports at least three times per weekVigorous activity:participation in extensive physical exercise for at least 60 min / session for at least 4 times per week or more
Medical and Family History

Type:

	Family	Self	If Self, how long?
Seizures
Migraines
Dementia
Mood disorders
Anxiety disorders
Eating disorders
Sleep disorders
Loss of consciousness
Previous head injury
Stroke
Parkinson's disease
Abnormal cholesterol
High blood pressure
Heart attack / Angina
Irregular heart rhythm
Asthma / COPD
Diabetes / high blood sugar
Thyroid disorder
Obesity
Kidney stones or disease
Liver disease / Hepatitis
Ulcers / Colitis
Arthritis
Gout
Osteopenia / Osteoporosis
HIV
TB
Autoimmune disease
Males persistent or painful erection (Priapism)

Surgeries and Hospitalizations
Reason / Diagnosis, Year:
Review of Systems

Please check YES to any symptom that you experience.

General:

	YES	Please describe
Anxiety / nervousness
Food cravings
Memory difficulties
Sadness
Concentration problems
Irritability
Night sweats
Excess fatigue
Weight loss or gain
Enlarged lymph nodes
Ringing in ears
Hearing difficulty
Dizziness
Hair loss

Cardiovascular:

	YES	Please describe
Chest pain at rest or exercise
Swelling of feet or legs
Leg pain with walking
Palpitations
Shortness of breath with exertion
Low blood pressure

Gastrointestinal:

	YES	Please describe
Abdominal pain
Constipation
Diarrhea
Bloating
Excessive belching / heartburn

Genitourinary:

YES Please describe

Kidney stones

	YES	Please describe
Kidney stones

Musculoskeletal:

	YES	Please describe
Back and/or neck pain
Joint pain - shoulder, elbow, knee, hip
Point tenderness - Where? Describe

Allergies, Medications, and Supplements
Allergies to Medications:

Prescription Medications:

	Medication Name	Dose & Frequency	Approx. Start Date	Reason for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Supplements and Over-the-Counter Medications:

	Medication Name	Dose & Frequency	Approx. Start Date	Reason for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Chemical Use History

Chemical Type:

	Age At Start	Age Of Regular Use	Describe Pattern (frequency, duration, amounts, type, method of use)	Last Use
ALCOHOL: Beer, Wine, Liquor
COCAINE/CRACK
CANNABINOIDS: Marijuana, Pot, Hashish
AMPHETAMINES: Crystal Meth, Crank, Speed, Ice, Diet Pills, Benzedrine, Dexedrine, Ritalin, Adderall, Methedrine, Vyvanse
HALLUCINOGENS: STP, PCP, LSD, Mescaline, Mushrooms, Ayahuasca, Peyote, Acid, Ketamine, Ecstasy
CAFFEINE: Soda, Tea, Coffee
NICOTINE: Tobacco, Dip
SEDATIVES: Downer, Quaaludes, GHB
SLEEPING PILLS: Seconal, Ambien, Dalmane, Restoril, Halcion
TRANQUILIZERS: Mellaril, Thorazine, Haldol
BENZODIAZEPINES: Valium, Librium, Xanax, Ativan, Tranxene, Klonopin, Serax, Centrax
OPIATES: Heroin, Demerol, Codeine, Methadone, Morphine, Dilaudid, Percodan, Darvon, Lortab, Opium, Percocet, Oxycontin, Soma, Ultram, Vicodin, Hydrocodone
INHALANTS: Gasoline, Glue, Freon

Other:

	Describe	Age At Start	Age Of Regular Use	Describe Pattern	Last Use
1.
2.
3.
4.

Psychosocial History
Have you ever been diagnosed with a psychiatric or mental health illness?*

YesNo
Please list diagnoses
Are you currently, or have you ever previously received treatment or support for substance use, emotional, or psychiatric problems?*

YesNo
Such as Therapy, Counseling, Supplemental support groups such as AA/Celebrate Recovery, etc.
Have you been hospitalized for any psychiatric diagnoses or substance use disorder in the past?*

YesNo
Inpatient(IP), Outpatient (OP), Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), etc.

Please list all treatment providers for emotional, psychiatric, or substance use: (Counselors, therapists, psychiatrists, psychologists, etc.)

	Treatment Site / Hospital / Provider	Date / Length of Treatment
1.
2.
3.

Are you currently seeing a social worker, counselor, psychologist, or psychiatrist?*

YesNo
Communication between Wellness Nashville providers and your primary care physician is important to help ensure that you receive comprehensive and quality health care. You may revoke this consent at any time except to the extent that the action has already been taken.

I, {name3}, for the purposes of coordinating care, authorize Wellness Nashville or any of the Mental Health Counseling team to contact my primary social worker, counselor, psychologist, or psychiatrist and discuss my current and historical diagnosis and treatment:

Address: Wellness Nashville, 100 Covey Dr. #309, Franklin, TN 37067 Phone: (615) 970-7882 Fax: (615) 523-1695

from my primary social worker, counselor, psychologist, or psychiatrist:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
My consent automatically expires (unless revoked earlier) one year from the authorized date below.
Signature:*

Clear
Date:

MonthDayYear
Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by the following problems?*

	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

PHQ-9 Score:
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?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:*

	Yes	No
1. Did a parent or other adult in the household often ... Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often ... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
3. Did an adult or person at least 5 years older than you ever ... Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?
4. Did you often feel that ... No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
5. Did you often feel that ... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Were your parents ever separated or divorced?
7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
10. Did a household member go to prison?

ACE Score:
Authorization for Use or Disclosure of Protected Health Information
Complete All Sections, Date, and Sign
I, {name3}, hereby voluntarily authorize the disclosure of Protected Health Information (PHI) from my health record for the purposes of medical treatment, mental health counseling and community care. The following details the PHI that may be shared between and among treatment partners for purposes of co-ordinate medical treatments, mental health counseling, and community care.

Wellness Nashville, PLLC contracts with Empower Health Services USA, LLC for treatment, billing, payment, collections, and operations. PHI is shared among these partners as needed to carry out the responsibilities for your treatment, billing, payment, collections, and operations. Subcontractors may be used and are covered through separate Quality Service Organization (QSO)/Business Associate Agreements (BAA). Revocation and expiration of this sharing is not possible.

Wellness Nashville, PLLC and Empower Health Services USA, LLC coordinates care with your mental health counseling team. PHI shared by Wellness Nashville include demographic info, psychosocial info, treatment from current or prior counselors / psychologists / psychiatrists, PHQ-9, ACEs, SCL-90R, AWARE, SOCRATES, DAST-10, GAD-7 and any other applicable assessments completed by me as well as any other information needed for coordinating my mental health counseling services as determined by Wellness Nashville and/or the counseling team members. Items shared by the counseling team members include your attendance and participation in your treatments and any high level concerns or suggestions that would help facilitate your recovery and re-entry into the community from which you were referred or to a care community of your choosing. All counselors will be covered by a QSO/BAA protecting your shared PHI.
If you have a mental health counselor that you wish to participate, please specify *:
Wellness Nashville, PLLC; Empower Health Services USA, LLC and one or more of the mental health team members coordinate care with your Community Care team. PHI shared includes your attendance and participation in your wellness treatments and any high-level concerns and/or suggestions that would help facilitate your recovery and re-entry into the community from which you were referred or to a care community of your choosing. All collaborative partners will be covered by a QSO/BAA protecting your shared PHI.
If you have a specific individual or organization you wish covered, please specify *:
* I understand that I may revoke this authorization in writing submitted at any time to the disclosing provider, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate one year from the date of my signature.

I understand that Wellness Nashville, PLLC requires my authorization below as a condition for treatment or eligibility for care.
Signature of Client or Personal Representative:*

Clear
Relationship to client:
Date:

MonthDayYear
Please verify that you are human:*
Should be Empty:

Wellness Nashville Client Info

Information Sheet

Emergency Contact

Insurance

Medical and Family History

Surgeries and Hospitalizations

Review of Systems

Allergies, Medications, and Supplements

Chemical Use History

Psychosocial History

Patient Health Questionnaire (PHQ-9)

Adverse Childhood Experience (ACE) Questionnaire

Authorization for Use or Disclosure of Protected Health Information

Complete All Sections, Date, and Sign