All in One Check in Form

JOHN W. GRACE M.D.,P.A.

CHECK-IN & PAYMENT FORM

IF IT HAS BEEN MORE THAN 4 MONTHS SINCE YOU'VE FILLED OUT THIS ENTIRE FORM PLEASE DO SO. IF YOU ARE A SELF-PAY PATIENT PLEASE SUBMIT YOUR ENTIRE PAYMENT OF $120.00 WITH THIS FORM.

NOTE: FAILURE TO PROPERLY SUBMIT THIS FORM OR COMPLY WITH PAYMENT SCHEDULE BELOW MAY RESULT IN SHORTER SUPPLY OF PRESCRIPTIONS WHILE WE DETERMINE APPROPRIATE ACTION. PATIENTS WITH EXCESSIVE BALANCES WILL LIKELY RECEIVE WEEKLY SUPPLY OF MEDICATION UNTIL LONG TERM PLANS FOR FOLLOW-UP OR TERMINATION ARE ARRANGED.

PLEASE SUBMIT PAYMENT IN FULL FOR SERVICES BELOW. WE UNDERSTAND THESE ARE DIFFICULT TIMES. IF YOU ARE NO LONGER ABLE TO AFFORD YOUR CARE HERE PLEASE SELECT THIS OPTION BELOW. YOU WILL BE GIVEN A SHORTENED SUPPLY OF MEDICATION AS WE DETERMINE WHEN YOUR TERMINATION DATE WILL BE AND WHAT FOLLOW UP YOU CAN ARRANGE.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
What is the purpose of this submission?*

I'm am making a payment on my balance. (Part I only)I'm preparing for a short tele-visit appointment and am currently stable (Part I only)I'm preparing for an in-office or more complicated visit or I wish to document the severity of my condition and disability. (Parts I and II)
What issues are most important to address at your next appointment? If routine follow-up or check in type "r."*
DID YOU IMPLEMENT OUR LAST PLAN? WHAT WAS RESULT OR NEW UPDATES SINCE THEN? If routine follow-up or check in type "r." *

OVER THE LAST TWO WEEKS I HAVE EXPERIENCED*

	NOT AT ALL(0)	SEVERAL DAYS(1)	> HALF OF DAYS(2)	ALL DAYS(3)
Little interest or pleasure in doing things:
Feeling down, depressed, or hopeless:
Trouble falling or staying asleep/sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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.
Thoughts that you would be better off dead, or of hurting yourself
Self-Destructive Self-Harm Behavior /Thoughts
Using Alcohol and Drugs
Isolating away from friends and family
Poor Sleep/ Wake Cycle
Significant Side Effects to Medication
Not Following Instructions Regarding Treatment
Disturbances in Reality (Hallucinations, Paranoia, Strong obsessions)
Significant anxiety that affects functioning.

MEDICATIONS NEEDED

*NOTE: TRY TO GET THESE REQUESTS IN ABOUT SEVEN DAYS EARLY AS THERE CAN BE MULTIPLE DELAYS (MISCOMMUNICATIONS, SUPPLY, INSURANCE, ETC.) 72 HOURS AFTER YOU SUBMIT THIS FORM, VERIFY THAT THE PRESCRIPTIONS ARE AT THE PHARMACY. IF NOT, CONTACT DR. GRACE ON HIS CELL PHONE.
WHICH MEDICATIONS WOULD YOU NEED REFILLED IN THE NEXT 30 DAYS. List pharmacy NAME, PHONE NUMBER and LOCATION (Ex. Walgreens Crystal River (352)-000-0000) *
HAVE THERE BEEN ANY CHANGES TO YOUR MEDICATIONS FROM OTHER PROVIDERS? IF SO PLEASE LIST ALL MEDICATIONS AND SUPPLEMENTS TAKEN OTHERWISE WRITE "NO"*
REMEMBER PAYMENTS

PLEASE SUBMIT PAYMENT IN FULL FOR SERVICES BELOW.

WE UNDERSTAND THESE ARE DIFFICULT TIMES.

IF YOU ARE NO LONGER ABLE TO AFFORD YOUR CARE HERE PLEASE SELECT THIS OPTION BELOW. YOU WILL BE GIVEN A SHORTENED SUPPLY OF MEDICATION AS WE DETERMINE WHEN YOUR TERMINATION DATE WILL BE AND WHAT FOLLOW UP YOU CAN ARRANGE.
REGARDING PAYMENT BELOW*

I BELIEVE I AM SUBMITTING PAYMENT IN FULL OR HAVE NO BALANCE WITH THE OFFICE.I AM PAYING FOR THIS VISIT IN FULL AS WELL AS STARTING TO PAY DOWN A PREVIOUS BALANCE. IF YOU ARE SELF-PAY THIS IS $120.00I AM UNABLE TO AFFORD MY CARE AT THIS TIME. I UNDERSTAND I WILL BE GIVEN A SHORTENED SUPPLY OF MEDICATION WHILE WE ARRANGE APPROPRIATE TERMINATION OF CARE AT THIS OFFICE AND FOLLOW UP.

Payment

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Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

1. I am NOT currently a danger to myself or others. Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room. The Vines in Ocala, Springbrook Hospital, Shands Hospital.

2. I have Dr. Grace's personal cell phone number and will contact him if there is a serious lapse in my care, understanding that he will return my call or deal with my issue within 24 hours.

3. I have read and accept the policies of John W. Grace, M.D.

Link here: POLICIES JOHN W GRACE MD PA

Including the following areas:

POLICIES
- PRIVACY

- BALANCES, LATE CANCELATIONS, AND FEES

- VISIT REQUIREMENTS AND TERMINATION

- THIRD PARTY PAPERWORK

- UNDERSTANDING AND MINIMIZING RISKS OF MEDICATIONS

4. I have read and accept the general instructions of John W. Grace, M.D.

GENERAL INSTRUCTIONS

Including the following areas:

GENERAL INSTRUCTIONS

HOW TO RELAX BY STRESSING YOURSELF OUT EACH MORNING.

HOW TO BALANCE YOUR IMPROVEMENT

HOW TO SEEK SERENITY MORE THAN EXCITEMENT

HOW TO KEEP A GOOD ROUTINE

HOW TO SEEK SUPPORT FOR GOOD DECISIONS

HOW TO BE MORE MINDFUL

HOW TO TRACK YOUR SYMPTOMS

HOW TO AVOID DESTRUCTIVE IMPULSES
Signature*

Clear
JOHN W. GRACE M.D.,P.A.

CHECK-IN FORM

PART II (OPTIONAL NOT REQUIRED)

THIS SECTION IS VOLUNTARY AND ALLOWS YOU TO UPDATE INFO OR ADD ADDITIONAL RATING SCALES. YOU MAY LEAVE THESE SECTIONS BLANK IF THEY ARE UNCHANGED FROM YOUR LAST VISIT. YOU MAY ALSO UPDATE THEM.

IF YOU WOULD LIKE TO TRACK THE SEVERITY OF YOUR SYMPTOMS OF ANXIETY, POST-TRAUMATIC STRESS DISORDER, EMOTIONAL REGULATION OR DISABILITY YOU MAY COMPLETE THE FOLLOWING SCALES. YOU CAN ALSO SIMPLY CUT, PASTE, AND UPDATE YOUR PREVIOUS TREATMENT PLAN FROM PATIENT FUSION IF IT IS AVAILABLE TO YOU.
YOU MAY CUT, PASTE, AND EDIT YOUR PREVIOUS TREATMENT PLAN FROM PATIENT FUSION RATHER THAN ADJUSTING EACH SECTION BELOW.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
How would you like us to communicate with you regarding appointment reminders?

You may email, text, or call me with reminders about my appointment.EmailText to the main phone number established with officeLeave a voice mail on the main phone number established with office.
EMERGENCY CONTACT AND OTHER PROVIDERS TO PROVIDE INFORMATION TO?
PREFERRED LOCATION FOR OBTAINING LABS

QUESTLAB CORPS (WALGREENS)CITRUS MEMORIAL HOSPITALSEVEN RIVERS HOSPITAL
IMPORTANT ANNOUNCEMENTS

Prior Authorizations is one of the most time consuming difficulty for obtaining medicaitons even generic. This process can take up to a month for us at times due to back log.

If you have a formulary, if you can upload a link to it here it will be helpful.
Please put a link to your plan's formulary
WHICH SYMPTOMS DO YOU FEEL HAVE IMPROVED THE MOST SINCE FIRST COMING?
Height
Weight
Recent Blood Pressure & Pulse
List all other Physicians treating you
May we update your other physicians with any recent changes in your care?

YesNoNot Applicable to me
HOW WILL OUR PROGRESS BE MEASURED:

We are going to be using a number of evidence-based psychological scales to track progress. The first two scales are specific to anxiety, and post-traumatic stress disorder. The third scale measures how we handle emotions and stress. The last is an assesment of disability.
GAD-7: TRACKS SEVERITY OF ANXIETY

This scale measures generalized worry and anxiety.

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

	Not at all (0)	Several Days (1)	More than half of Days (2)	Nearly Every Day (3)
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

PCL-5

This scale tracks the severity of Post Traumatic Stress Disorder

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

	Not at all (0)	A little bit (1)	Moderately (2)	Quite a bit (3)	Extremely (4)
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being “super alert” or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?

The Difficulties in Emotion Regulation Scale (DERS) is an instrument measuring emotion regulation problems.

This scale measures an integrative conceptualization of emotion regulation.

A substantial body of research has shown significant positive associations between scores on the DERS (specifically the total score) and symptoms of a range of psychological disorders, including borderline personality disorder (Gratz et al., 2006), generalized anxiety disorder (Mennin et al., 2002), substance use disorders (Fox et al., 2007; Gratz and Tull, 2010), social anxiety (Rusch et al., 2012), health anxiety (Bardeen and Fergus, 2014), post-traumatic stress disorder (Ehring and Quack, 2010), and bipolar disorder (Becerra et al., 2013; Van Rheenen et al., 2015).

PLEASE ANSWER BELOW

	Almost Never (0)	Sometimes (1)	About half the time (2)	Most of the Time (3)	Almost Always (4)
1. I pay attention to how I feel.
2. I have no idea how I am feeling.
3. I have difficulty making sense out of my feelings.
4. I am attentive to my feelings.
5. I am confused about how I feel.
6. When I’m upset, I acknowledge my emotions.
7. When I’m upset, I become embarrassed for feeling that way.
8. When I’m upset, I have difficulty getting work done.
9. When I’m upset, I become out of control.
10. When I'm upset, I believe that I will remain that way for a long time.
11. When I'm upset, I believe that I'll end up feeling very depressed.
12. When I'm upset, I have difficulty focusing on other things.
13. When I'm upset, I feel ashamed with myself for feeling that way.
14. When I'm upset, I feel guilty for feeling that way.
15. When I'm upset, I have difficulty concentrating.
16. When I'm upset, I have difficulty controlling my behaviors.
17. When I'm upset, I believe that wallowing in it is all I can do.
18. When I'm upset, I lose control over my behaviors.

The next assessment is a WHODAS 2.0 which is a standardized self-assessment of disability. Answer each of the following questions regarding how much difficulty did you have in the following areas using the following scale from 1-5.

(1)= no difficulty

(2)= mild difficulty

(3)= moderate difficulty

(4)= severe difficulty

(5)= extreme difficulty or unable to accomplish at all

Type a question

	1	2	3	4	5
1. Standing for long periods such as 30 minutes?
2. Taking care of your household responsibilities?
3. Learning a new task, for example, learning how to get to a new place?
4. How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
5. How much have you been emotionally affected by your health problems?
6. Concentrating on doing something for ten minutes?
7. Walking a long distance such as a kilometre [or equivalent]?
8. Washing your whole body?
9. Getting dressed?
10. Dealing with people you do not know?
11. Maintaining a friendship?
12. Your day-to-day work?

In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
UPDATE YOUR WELLNESS PLAN

If you haven’t done a formal impulse control plan see the link here and do so.

https://form.jotform.com/203133142590040

Doing it and reviewing it is one of the most important things you can to maintain productivity and mental wellness. After you do it, make a copy. Then periodically paste and update your impulse control plan here.

TRIGGERS

WARNING SIGNS

COPING SKILLS, PLACES, AND PEOPLE

CHANGES TO ENVIRONMENT TO AVOID DESTRUCTIVE IMPULSIVITY

PROFESSIONALS I CAN REACH OUT TO

DIAL 911 OR GO TO ANY EMERGENCY ROOM FOR PSYCHIATRIC EMERGENCIES AS WELL AS MEDICAL

Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)
Citrus County Lifestream Crisis Line: 866-355-9394
Veteran Crisis Line: 1-800-273-8255. (Text 838255)

Local Urgent Psychiatric Services

The Vines Psychiatric Hospital
24 hour Emergency care and Hospitalization
866-671-3130
https://thevineshospital.com/
3130 Southwest 27th Ave. Ocala, FL 34471

Springbrook Psychiatric Hospital
24 hour Emergency care and Hospitalization
352-600-3288
https://www.springbrookhospital.org/
7007 Grove Road, Spring Hill, FL

Lifestream Behavioral Center
Medication, therapy and 24 hour Emergency care and Hospitalization
866-355-9394
https://www.lsbc.net/
MY WELLNESS PLAN (TRIGGERS, WARNING SIGNS, COPING SKILLS, ETC)
What do you see as your current needs or limitations?

Physical ProblemsThinking ProblemsBehavioral ProblemsAddictive BehaviorsLegal ProblemsMedical ProblemsLearning DifficultiesCommunication disorderDevelopmental disabilityVision problemsHearing problemsPhysical disabilitySocial factorsEnvironmental factorsSocio-Economic InstabilityTransportation
What do you see as your current strengths?

Family/Social/Community SupportAverage to Above Average Cognitive AbilityInsight/JudgmentAltruisticSocio-Economic StabilityCoping Skills and ResiliencySelf-EfficacySelf-ConfidenceMotivated for Change Focused TreatmentSpiritualityExternally MotivatedRecovery HistoryDesires Employment/Volunteering/Meaningful ActivityRelationship StabilityPhysically HealthyPerseveranceEmotional StabilitySense of HumorParenting/Caregiving SkillsMakes Use of EducationGainfully EmployedSpeaks More Than One LanguageCan Effectively Use TransportationVocational/Trade SkillsEffective Money ManagementHealthcare System Navigational SkillsAbility to Appropriately Self-AdvocateCommunication SkillsMaturity and Judgment SkillsInterpersonal Skills
You know we encourage journaling, routine, and self-support and the monitoring and protection of your story. Every story has three parts, where you started, where you have been, and where you are. The first part tends to change little (except as we learn more about our past) but the second two are always changing. We recommend patients keep a copy of their story and update it periodically. Feel free to copy, paste, and edit the current version of you and we'll discuss it at your appointment. What are your current strengths, limitations, and goals for the next six months of your life and care with the office?
Should be Empty:

JOHN W. GRACE M.D.,P.A.

CHECK-IN & PAYMENT FORM

IF IT HAS BEEN MORE THAN 4 MONTHS SINCE YOU'VE FILLED OUT THIS ENTIRE FORM PLEASE DO SO. IF YOU ARE A SELF-PAY PATIENT PLEASE SUBMIT YOUR ENTIRE PAYMENT OF $120.00 WITH THIS FORM.

MEDICATIONS NEEDED

REMEMBER PAYMENTS

JOHN W. GRACE M.D.,P.A.

CHECK-IN FORM

PART II (OPTIONAL NOT REQUIRED)

IMPORTANT ANNOUNCEMENTS