Medical Wellness: Patient Packet

Medical Wellness: Patient Packet

Medicare patient's only
Patient Information
Patient Name:
Sex
Date of birth

MonthDayYear
Date
Address
#APT
City
State
ZIP
Phone (Home)
Please enter a valid phone number.
Phone (Cell)
Please enter a valid phone number.
Email
example@example.com
Social Security#
Marital Status

SingleMarriedDivorcedWidowedDomestic Partnership
Ethnicity

Hispanic/LatinoNot Hispanic
Race
Language
Insurance Number
Secondary Insurance
AUTHORIZATION OF TREATMENT
Authorization and release for Docs Medical/ Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center), hereby referred as Docs Medical Group. I voluntarily consent to the administration and costs of medical and surgical procedures for myself or my dependent.

ASSIGNMENT OF INSURANCE BENEFITS/GUARANTEE OF PAYMENT
I authorize payment directly to Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center) for all benefits payable to me. I understand that I am financially responsible and agree to pay all charges that are not paid or billed to my insurance or any third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance is accepted I must pay all applicable insurance co-payments, co-insurance, or deductible for services. I understand all services rendered are non-refundable under any circumstance. I understand that is I do not pay within 90 days upon receiving my billing statement; my account will be transferred over to “American Adjustment Bureau.”

RELEASE TO RECORDS
I authorize Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center) to release (verbal or written) confidential medical information to any person or entity including my insurance carrier, employer (if treatment is related to employer purposes), or other health care operations which may be liable to me or my practitioner(s) for changes in treatment, for quality management, utilization review, transfer, and follow-up purposes.
Signature

Clear
Date

MonthDayYear
Date
Relationship to Patient
Patient name
Social History

Check all that applies
Tobacco

Current
Type
Frequency

2nd handNeverPrior use
Quit Date
Alcohol

NeverOccasionalDaily
History of Alcoholism: (describe)
Drug abuse

NeverOccasionalDailyPrior use
Quit Date
History of drug abuse:(describe)
Employment

Employed fulltimeEmployed part timeUnemployed
Education level

Some High schoolHigh school diploma/GEDSome college courseworkCollege DegreePost graduate education
Caffeine

NeverOccasionalDaily
Home environment

Private homeAssisted livingNo housing (shelter, car, homelessWorried about losing housingFeels physically and emotionally safe in current living situationOther:
Describe other home environment:
Housing status (check all that applies)

Lives aloneLives with spouse/partnerLives w/ childrenLives with petsLives with smoker
How people live with you:
Social Functioning and Interaction

No concerns, maintains adequate social lifeSocial anxietyPrefers isolation and limited social interactionDifficulty w/ interpersonal relationships

Patient Health Questionnaire (PHQ9)

	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, or 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 figety 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

If you checked off any problem, 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 difficultSomewhat difficultVery difficultExtremely difficult

Family History (Check all that apply)

	Self	Father	Mother	Sisters	Brothers	Aunts	Uncles	Daughter	Son
Deceased
Hypertension
Heart Disease
Stroke
Kidney Disease
Obesity
Genetic Disorder
Alcoholism
Liver Disease
Depression or Manic Depressive Disorder
Colon or Rectal Cancer
Breast Cancer
Other Cancer
Other...

...Describe other Family History
Medical History (since last visit)
Surgical History
Medication List
Problem List
Patient Name
DOB
Please list all of your current providers and suppliers of health care
Primary Care Physician / Provider(s)
Specialist(s): (ie. Cardiologist, GI, Neurology)
Alternative medicine providers (ie. Chiropractors, acupuncturist, etc.):
Preferred Pharmacy (s): Name & Location
Dentist
Other
Patient Name
DOB
Wellness: Health Risk Assessment
In general, would you say your health is:

ExcellentVery GoodGoodFairPoor
How have things been going for you during the past 4 weeks?

Very Well; could hardly be betterPretty wellGood and bad parts about equalPretty badVery bad; could hardly be worse
How confident are you that you can control and manage most of your health problems/Issues?

Very confidentSomewhat confidentNot very confidentI do not have any health problems

How often in the last 4 weeks have you been bothered by any of the following problems?

	Never	Seldom	Sometimes	Often	Always
Falling or dizzy when standing up
Sexual problems or concerns
Trouble eating well
Teeth or denture problems
Problem using the telephone
Tiredness or fatigue
Problems sleeping

Have you fallen two or more times in the past year?

YesNo
Are you afraid of falling? Do you feel unsteady?

YesNo

Home Safety Checklist

	Yes	No
Are entrance ways well lit?
Are sidewalks/entrance well maintained?
Is a carbon monoxide detector installed?
Are smoke detectors installed?
Are all medicines kept in original containers with original labels intact?
Do you throw out all unidentified or out-of-date medications?

How often do you have trouble taking medicines that way you have been told to take them?

I do not have to take medicineSometimes I take them as directedI always take them as directedI seldom take them as directed
Are you having difficulties driving your car?

YES, oftenSometimesNON/A
Do you always fasten your seat belt when you are in a car?

Yes, alwaysYes, sometimesNo

How often in the last 4 weeks have you experienced the following: (Hear loss screening)

	Never	Seldom	Sometimes	Often	Always
Straining to understand conversation
Trouble hearing in a noisy background
Misunderstanding what others are saying

During the past 4 weeks, how much bodily pains have you generally had?

No PainVery mild painMild painModerate painSevere pain
Do you have someone who is available to help you if you needed or wanted help?

Yes, as much as I want/needYes, someNo, not at all
Because of any health problems, do you need the help of another person with shopping, preparation of meals, or housework?

YesNo
Because of any health problems, do you need the help of another person with your personal care needs, such as eating, bathing, dressing, or getting around the house?

YesNo
Can you handle your own money without help?

YesNo
What is your nutrition and diet? (Check all that apply)

Healthy well-balanced dietUnhealthy dietWeekly dining outDisordered eatingTakes vitamin/minerals/ herbal supplementsProblems with meal preparationBinge eatingOvereatingExtended periods of time without eating
During the past 4 weeks, did you exercise for about 20 minutes, 3 or more days a week?

Yes, most of the timeYes, some of the timeNo, I usually do not exercise this muchNo, I am not currently exercising
When you exercise, how intensely to you typically exercise?

Light (stretching/ slow walking)Moderate (brisk walking)Heavy (jogging/ swimming)Very heavy (running/stair climbing)
In the past 7 days, on how many days did you drink alcohol?
Ex: 2 days
On days when you drank alcohol, how often did you have 4 or more drinks?

NeverOnce during the week2-3 times during the weekMore than 3 times during the week
Advance care planning: Do you have an advance directive on file?

YesNoI would like to have one
In the past 12 month, have you or your household been without:

Transportation to medical appointmentsClothingFoodUtilitiesChildcareHealthcarePhoneNone
Thank you for completing this Wellness Health Risk Assessment.
ACKNOWLEDGE OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Authorization and release for Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center), hereby referred to as Docs Medical Group.

This document is to be signed by the person legally responsible for the patient’s medical decisions relative to the treatment
situation.

I hereby acknowledge that DOCS Medical Inc. has provided me with a copy of its notice of privacy policies that describe how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have question or complaints, I may contact DOCS Medical Inc. Administration Directors at 203-874-3682 or by e-mailing contact@DOCSofct.com.

I also understand that I am entitled to receive updates upon request if and when for Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center), amends or changes its notice of privacy practices material in any way.

I allow Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center), to obtain prescription history from an external source:
Signature

Clear
Date

MonthDayYear
Date
Relation to the patient
(If signed by someone other than the patient)
My preferred contact number to call or text regarding an appointment, labs or other tests/ consultations is
Please enter a valid phone number.
Consent for Notification of Test Results
I give permission to Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center) to notify about my health information.

I give permission to Docs Medical Group/Docs Urgent Care and its subsidiaries (Docs of CT, Zen Health and Wellness, Epic Family Physicians, Continuum Medical Group, 203 Urgent Care and Urgent Care Center) to share health information via voicemail or text message.
Signature

Clear
Date

MonthDayYear
Date
Relation to the patient
(If signed by someone other than the patient)
Should be Empty:

Medical Wellness: Patient Packet

Patient Information

Social History

Wellness: Health Risk Assessment

Consent for Notification of Test Results