New patient form

Harris Robert Jensen, MD, LLC
Certified American Board of Psychiatry and Neurology
1019 Remington Street
Fort Collins, CO 80524
Phone 970-416-8354
We would like to welcome you to our office and look forward to working with you. Please take a few minutes to look over, read, fill out, and then sign the following infor-mation.
New Patient Information
Prior to your evaluation, it is very important to fill out this form in as much detail as pos-
sible. Thanks in advance for taking the time to complete this form. The more informa-
tion you are able to provide, the more the doctor will be able to help you by having a
more complete understanding of your life and what recently has been going on. There-
fore, all this information is important! Please print clearly. We realize that your time is
valued, as is the time of the doctor and his staff. This form will take about 40 minutes of
your time to fill out, but it really helps speed up the whole process of evaluating your
concerns and helps the doctor get information on your concerns more quickly.
Age _____ Social Security Number _____ _____ __________ Emergency notification: (someone not currently living with you): Patient’s home address: ________________________ City: __________________ State: ____________ Zip: _________________ Home Phone: ___________________ Cell Phone: __________________ Home Mailing Address: _______________________________ City: _________________ State: __________ Landlord’s Name: _______________________ Referred by: ________________ Doctor Friend Therapist Family Member (Circle One) If a student, name of school attending: ______________________________ If employed, name of employer: ________________________________ work phone: _________________ extension __________ address: ________________________ City __________ State ____________ spouse’s employer: ___________________ Work phone: _______ extension ________ Will we be billing you or your insurance for this visit: ______ self ______ insurance Future visits? _____self __________insurance Person who will be responsible for bill, other than insurance: __________________ Social Security Number: _______________ Date Of Birth: ____________________ Patient’s relationship to responsible party: ___Self ___ Spouse ____ Parent ____ Guardian Other: ______________ (Please Explain) Mother or Guardian’s Name: ________________________ Date Of Birth: _________ Social Security Number: ___________________ Address: (If Different From Above) _______________________________________ City: __________________ State: _____________ Zip Code: _____________ Phone Number: _______________ Employer: ________________________ Occupation: _________________ Work Phone Number: __________________ ext _____ Father or Guardian’s Name ___________________________ Date Of Birth: ____________ Social Security Number: _________________ Address: (If Different From Above) _______________________________________ City: __________________ State: _____________ Zip Code: _____________ Phone Number: _______________ Employer: ________________________ Occupation: _________________ Work Phone Number: __________________ (Please Circle One Of The Sentences Below, Either Number 1 or Number 2, Thank You) 1. I either do not have insurance or do not wish to bill my insurance company for serv-ices provided to me by this office and I agree that I am responsible for payment on my account for any charges incurred as a result of these services.
2. I would like your office to bill my insurance for covered services. (I agree to see my insurance agreement or call my insurance to see what services are covered.) Authorized Signature: _______________________ Date: _____________ Relationship To Patient: self spouse parent guardian other: ___________ We participate with most major insurance companies. Please check with your insur-ance to be sure we are a participating provider with them. You insurance company may also require an “authorization number” for you to see Dr. Jensen and them to pay for services. You will need that number for your first visit. this number authorizes your visit and payment for Dr. Jensen’s services. You will need that number to show the Office Assistant at your first visit! You can ask your insurance company to send an authoriza-tion letter to us. This provides proof that your insurance has aghreed to pay for your visit. After the initial authorization for payment, our office will contact your insurance for additional “authorizations.” Please don’t forget to bring your insurance car or your authorization number with ytou to your first visit with us otherwise you may be charged for the full amount of the visit until coverage information can be determined.
If you are between jobs or lose insurance--please let Dr. Jensen know, and keep seeing him.People often find that between using generic medication and other things, it doesn’t cost more to continue their medical care with Dr. Jensen once they are off in-surance. And to go off medication and see their mental health problems come back--that really hurts their ability to interview well as they seek another job.
Insurance Company Name: ________________________________________ Policy Holder’s Name: ____________________________________________ Relationship To Patient: _____ Self ___ Spouse _____ Parent ___Guardian ___ Other: please explain ______________________ Employer Name: _____________________________ Member ID Number: ___________________________ Policy Holder’s Date Of Birth: ____________________ Policy Holder’s Social Security Number: _________________________________ Visit Authorization Number: _________________________________ If an HMO/PPO/EAP/IPA plan, have you called insurance for a referral? (If insurance requires a referral and you have not called for a referral, then insurance may not accept responsibility for paying for services from Dr. Jensen, and that will then rest with you as the responsible party. Please call you insurance company for a referral to tap into your benefits due to you as a policy holder.) BOTH OF THE WAIVERS BELOW MUST BE SIGNED PRIOR TO YOUR FIRST VISIT WITH THIS OFFICE.
THESE WAIVERS LET YOUR INSURANCE KNOW THAT WE ARE FILING CHARGES, AS A PARTICIPATING PROVIDER, FOR YOUR VISITS WITH DR. JENSEN.
Failure to sign does not release you from liability for these charges.
Please make sure we participate with your insurance.
(If you do not sign, then we are not able to bill your insurance company for payment on your behalf and you will be responsible for the full amount of the bill.) This waiver allows our office to submit the charges to your insurance for payment for services provided to you on your behalf.
“I AUTHORIZE PAYMENT OF PSYCHIATRIC BENEFITS DIRECTLY TO HARRIS R. JENSEN, MD, LLC, PROVIDED THAT HARRIS R. JENSEN, MD, LLC, IS A PARTICI-PATING PROVIDER WITH MY INSURANCE COMPANY. I ALSO UNDERSTAND THAT INSURANCE IS BEING FILED AS A COURTESY ON MY BEHALF AND THAT ULTI-MATE RESPONSIBILITY FOR PAYMENT FOR SERVICES IS MINE. INITIALLY, I WILL ONLY BE ASKED FOR MY COPAYMENT, COINSURANCE, AND OR MY DEDUCTI-BLE AT THE TIME OF SERVICE. BUT IF THERE IS A DIFFERENCE FROM WHAT WAS PAID PER MY INSURANCE AT THE TIME OF MY VISIT FOR EITHER MY CO-PAY, COINSURANCE, AND OR DEDUCTIBLE AMOUNTS, ETC., THEN I AM RE-SPONSIBLE FOR PAYING THE REMAINING BALANCE, IN FULL, AT THAT TIME. “IF PAYMENT IS NOT RECEIVED FROM INSURANCE WITHIN 45 DAYS OF FILING WITH MY INSURANCE, I WILL BE GIVEN A GRACE PERIOD OF UP TO 10 DAYS TO RESOLVE ANY BILLING ISSUES WITH MY INSURANCE COMPANY. HOWEVER, WITHIN 30 DAYS PAST THE INSURANCE PAYMENT DEADLINE, PAYMENT IN FULL IS EXPECTED. I ALSO AUTHORIZE THE RELEASE OF ALL INFORMATION NECES-SARY FOR THIS OFFICE TO PROCESS INSURANCE CLAIMS AND/OR TO DO CASE MANAGEMENT, AUTHORIZATIONS, AND WHEN NECESSARY TO FORWARD INFORMATION TO THE STATE INSURANCE COMMISSIONER’S OFFICE OR OTH-ERS IN ORDER TO RESOLVE BILLING ISSUES WITH MY INSURANCE COMPANY.
“PLEASE NOTE: IF YOU HAVE HEALTH INSURANCE, IT IS NOT A GUARANTEE THAT THEY WILL PAY FOR SERVICES RENDERED BY THIS OFFICE, EVEN IF ALL BILLS ARE SUBMITTED APPROPRIATELY. PLEASE REVIEW YOUR HEALTH BENE-FIT PLAN TO UNDERSTAND WHAT IS OR IS NOT COVERED. YOU ARE ULTI-MATELY THE PERSON RESPONSIBLE FOR MAKING SURE OUR OFFICE RE-CEIVES PAYMENT OF YOUR BILL IN A TIMELY MANNER, REGARDLESS OF THE STATUS OF YOUR CLAIM WITH YOUR INSURANCE. THE BILL FOR MEDICAL SERVICES OUR OFFICE PROVIDES TO YOU ON YOUR BEHALF, IS AN AGREE-MENT BETWEEN YOU AND THIS OFFICE THAT YOU WILL BE RESPONSIBLE FOR PAYMENT OF THESE SERVICES. IF YOUR INSURANCE DOES NOT PAY WITHIN 45 DAYS, THEN 90 DAYS AFTER THE BILL WAS SUBMITTED YOU MAY BECOME RESPONSIBLE FOR ADDITIONAL LATE FEES AND OFFICE CHARGES. PLEASE CHECK WITH YOU INSURANCE TO VERIFY WE ARE A PARTICIPATING PROVIDER WITH THEM. IF WE ARE NOT A PARTICIPATING PROVIDER, OUR OFFICE CAN SUBMIT CHARGES TO THEM, BUT YOU WILL BE ASKED TO COVER THE DIFFER-ENCE BETWEEN WHAT INSURANCE PAYS AND THE ACTUAL CHARGES.
“SIGNING BELOW DESIGNATES THAT I HAVE READ AND UNDERSTAND THE ABOVE PARAGRAPHS IN WAIVER NUMBER 1.” AUTHORIZED SIGNATURE: _____________________________ DATE: __________ “I understand that some additional services I may request from this office, including ex-tensive telephone consults with Dr. Jensen, or with other persons in the office, written reports, review of records, record copying, some types of testing, medication, authoriza-tions from insurance, medication refills, etc., which may not be covered by my insurance company. In those circumstances I understand that I will be billed for these services. I also understand that I will be billed the full amount of the visit when I have missed ap-pointment and/or made late cancellations. My medical care is a top priority item in my life and I am responsible for informing work and school persons as needed to avoid conflicts with my medical visits. In addition, I understand that I could be billed for other outside services performed on my behalf by other qualified doctors or labs in conjunc-tion with this office.” “Signing below designates that I have read and understand the above paragraph of waiver number two.” Authorized signature:__________________________ Date: ________________ Taking personal responsibility for controlling one’s own emotions and behavior is a basic principle for therapy. Therefore, in taking responsibility for your appointments and bill, and to understand these complexities involved in insurance billing, this is all a great ac-complishment in the process of therapy. It sets the stage to learn to take responsibility for other concerns! Our experience has shown it is helpful to have a clear understand-ing with our patients about our office procedures and financial policy. We hope you un-derstand that our credit and collection policies are a necessary part of doing business and help “keep our doors open.” Therefore, the following policies have been developed with much care and thought. Please feel free to ask if you have any questions regard-ing these policies.
(Please initial and date each page that follows to indicate you’ve read and understand these policies. Thank you! HJ) We are committed to providing professional care for you and to support this we ask all our patients to be open with Dr. Jensen and his staff and share any frustrations you may have during the course of your work with him.
Medical care is complex. If Dr. Jensen is running late for your appointment, he appreci-ates your patience. Emotional and behavioral problems take time to be understood. Emergencies occur. This is often frustrating for many people receiving care, as they try different medications and counseling approaches to find relief from their concerns.
Emergencies. If an emergency occurs, please go immediately to the nearest Emer-gency Room or call 911. Our office is not equipped to deal with urgent situations and your care will be best handled by the nearest hospital.
Appointment time is valued. We ask that patients take personal responsibility for keep-ing track of their time and making it to their appointment on time. If you are unable to keep you appointment, please cancel within 24 hours by contacting our office during regular business hours, which are Monday to Thursdays 9 am to 6 pm and Fridays from 9 am to 1 pm, so we can allow for other clients to utilize this time. If an appointment is cancelled AFTER business hours (on evenings or weekends) or cancelled with less than 24 hours notice, unless an emergency, you may be charged for the full amount of the visit. Work conflicts are charged as they are not an emergency, and the same goes for school conflicts. To help you remember your scheduled visits, we give a schedule card with the time of your next appointment. Please write this information down on your calendar or day timer or in a place that will help you remember the visit.and remember to look at it! Reminder Calls. When office time permits, we try to give patients reminder calls when-ever possible. PLEASE DO NOT RELY ON THESE CALLS TO REMEMBER YOUR APPOINTMENT!!!!!!!!!!! PLEASE DO NOT USE THESE CALLS AS A TIME TO RE-MEMBER TO CANCEL YOUR APPOINTMENT!!!!!!!!!!!!! Our office may have trouble getting through to you or run into problems having time to make calls to patients be-cause other more urgent patient matters can come up. Again, it is totally up to you to make it to your appointment on time. Often a reminder call is made and a message left on an answering machine or with another person.and the message never gets to the patient for one reason or another. All we can do is do our best to make the call. If you miss your appointment because you never got the reminder call for one reason or an-other, you are still responsible to make it to the appointment and you likely will be charged for the missed appointment.
Medication. Please don’t stop or change medication on your own without first talking to the doctor. There are potentially serious risks to your health if you change medication on your own.
Medication refills. Medication refills should be taken care of during your appointment with Dr. Jensen.
PLEASE DON’T HAVE THE PHARMACY CALL THE DOCTOR’S OFFICE FOR A MEDICATION REFILL IF YOU HAVE RECEIVED A WRITTEN PRESCRIPTION. We get about 1,000 such requests every year! What a waste of your time and ours! And we always send back the same answer: if you receive a written prescription for a medi-cation, the doctor can’t “double prescribe” and call in the same prescription to a phar-macy. If you get a written prescription, then you need to use it, and within 30 days, after that time it is considered too old and a pharmacy may well reject it. You can turn it in for the pharmacy to put on their computer, however, and then you can have the prescription filled later.
Medication prescriptions and cancelled appointments. Prescriptions are given with enough refills to make it to the next agreed upon appointment. If you cancel an ap-pointment then you need to reschedule it before medication runs out. If medication runs out and you call for a refill of medication, you may be charged $10 for a late refill of medication. Emergency requests for medication and weekend refills on medication are $15. Please look ahead and get in to see the doctor at least two weeks before the medication is due to run out. If your medication is about to run out, first call the phar-macy and have them fax us a refill request.
Refill requests for Ritalin, Dexedrine, Adderall and other stimulant medications cannot be called in to a pharmacy! They must be written out and then you or a guardian of the patient can pick it up.
Refills across the state boundary of Colorado can’t be done. Dr. Jensen cannot call in a prescription to a pharmacy in another state or country.
Insurance. (Please see Insurance Agreement.) We participate with most major insur-ance companies. For non participating insurance companies, we can still submit a claim to them on your behalf, but you will be asked to cover the difference in the amount not covered by your insurance. Please make sure our office is given the proper infor-mation in order to bill your insurance company. Your visits with the doctor are normally covered by insurance and will be submitted to them for payment. However, not all serv-ices performed by either the office and/or the doctor may be covered by insurance. You will be asked to pay for these services up front. Figuring out whether or not your insur-ance will pay for covered services is ultimately your responsibility because insurance is a service, of course, that you have chosen to provide a service to you! Insurance is a service you pay for, with the insurance agreeing it will pay for a part of covered services provided to you. What your insurance does for you is determined by your contract with them.
What your doctor provides for you is determined by your contract with the doctor.
We allow up to 45 days for your insurance to pay your bill. After that, you will be asked to pay the charges due and you then will need to follow up with your insurance company for reimbursement.
If insurance doesn’t pay, that doesn’t affect this contract between you and your doctor, and your promise to pay your bill even if the insurance company doesn’t pay.
If our office needs to rebill your insurance more than two times for any reason and/or bill a different insurance company other than the one we currently have on file at the time of yor visit, your account will be billed a $2.00 reprocessing fee. Please make sure to keep our office updated with any changes to your insurance information and to provide us with copies of your new card at the time of your visit. If you get new insurance and don’t tell us, then we will bill the old insurance company, it will be rejected, and likely the new insurance won’t pay the bill, and the bill will come back to you to pay in full! Payment in full is expected at the time of service. Charges for both covered and non-covered medical services at our office, including co payments or deductibles, etc., are due and payable at the time of service. We accept cash, checks, Visa, and Master Card. Certain services may not be provided until payment in full has been received. Please make sure your account with our office remains in good standing to avoid delays or additional charges on your account. If your account becomes delinquent for any rea-son, we may not be able to schedule your next appointment until it is fully paid up. If you are not sure what is owed on your account prior to your visit, please contract our office to find out the current balance due. If you request our office to bill you for the payment due at the time of service, you may be charged a $2.00 fee for office time.
Returned check fee. Any returned check issues will be charged $20.00 plus a $15.00 office fee or whatever the bank fee is plus $15.00. The minimum charge billed to your account is $35.00.
Third party billing. There is a $3.00 office fee that will be billed to your account if you request our office to bill another party, other than insurance or yourself, for payments on your account. Moving. If you move and don’t leave us your new address, then of course we won’t be able to find you to send any bills on unpaid balances. If no forwarding address is found then the bill is turned over for collections which goes on your credit report and can be an issue in anything in the future that involves a credit report.
Phone calls are answered as soon as the Doctor or the office has time. Please allow up to 24 hours for a response. We need to know the phone number where you can be reached during and after regular business hours. The doctor will call you back right away in you inform the receptionist there is an emergency or urgent situation. Non-urgent calls exceeding 5 minutes will be charged $5 per each 5 minutes of time. Dr. Jensen is not able to do “phone visits.” You will need to schedule an appointment to talk with Dr. Jensen about medicine and therapy issues.
Paperwork. There is a charge for all reports, forms or letters outside of normal office functions. some examples: legal forms, work related forms, disability forms, additional insurance form requests, copy of records. Please allow 5-7 business days for comple-tion and payment must be receiving prior to their release. Please review all the informa-tion requested to make sure it meets you requirements. Charges vary per request: forms, $5/page; letters $10-$20; record copies, $15 for first 10 pages; and insurance forms $5 per page.
Authorizations. There is no charge for authorizations requests for your visits. However, a charge of $10 per form will be assessed when our staff has to resolve Insurance/Authorization issues when not part of the normal authorization process. In addition, when requested by the patient, a charge of $16 per hour or a minimum of $5 per phone call, will be billed to your account for calls made by the office to your insurance to re-solve any type of payment/claim issues. We are not employees of the insurance com-panies and insurance does not pay for these services.
Payment Plans. Account balances that are 90 days past due are charged an additional monthly 1.5% finance charge and a $3 office fee. Once charges have been assessed on your account, we may be unable to deduct them from your bill, however, future charges may be avoided by establishing a payment plan and making timely payments with our office. If unusual circumstances make it difficult for you to meet our credit terms, please contact or personally speak with our office staff (not Dr. Jensen) immedi-ately to discuss the matter. This will help to avoid any misunderstandings and enable you to keep your account in good standing with us.
Collections process. We do everything we can to help bill your primary insurance, how-ever,, until you or your insurance company assumes responsibility for payment of the services rendered, the responsibility ultimately rests with you. Accounts that are 90 days past due, will be billed a 1.5% finance charge and a $3 office fee and may be re-ferred to a collections agency, unless you have made prior arrangements with our office. Inn the event your account is turned over to a collections agency or service, you will be billed an additional $25 fee to process the collections paperwork with a collections agency. You will also be billed and be responsible for any administration fees for the office and Dr. Jensen to review your account and file, phone calls or attempts to collect the outstanding bill, and/or the collections fees in addition to your original outstanding balance. If it becomes necessary to enforce a judgement against you, the additional applicable court and attorney fees will also be your responsibility. A lien may be placed against your property. Accounts turned over to collections agency may result in the automatic dismissal of you as a patient of Dr. Jensen.
We are always looking for a better way to function in the office. Your thoughts, com-ments and constructive criticism have gone into what you’ve read above and more comments will be carefully considered. Please talk to us if you have any additional ideas.
I understand that my mental health needs to be the top priority in my life in order for other areas of my life to go well, which includes both my personal and professional life. Therefore, my medical visits need to take a top priority in how I budget my time, and I need to let my boss or teachers know of my visits.
I agree to do whatever it takes to make it to my appointment on time. If I am not able to make it to my scheduled appointment, I will show the office and doctor the courtesy to call within 24 hours to cancel or change my appointment time so that I can allow some-one else the chance to use that time.
I agree to tell the truth to the doctor. I understand it can be dangerous to my health to not tell the truth to the doctor, because he may not then have an accurate understand-ing of my medical needs.
I agree to respect and treat the office staff with common courtesy. That I will do my best to discuss problems or concerns with them in a respectful manner whenever I need to speak with them because I understand that they want to help me.
I understand that responsibility for payment of any medical services I receive from this office is an agreement between myself and this office and that I am ultimately responsi-ble for payment of my bill. I understand that there are services performed by this office that may not be covered by my insurance company and that I am responsible for them.
I understand that Dr. Jensen and his staff are not employees of the insurance compa-nies.
I understand that Dr. Jensen and his staff are not employees of the insurance compa-nies.
I understand that this office is billing and working with my insurance company as a cour-tesy to me as their client and that it is not the fault of this office when my insurance does not assume responsibility for payment of charges.
I understand that this office is billing and working with my insurance company as a cour-tesy to me as their client and that it is not the fault of this office when my insurance does not assume responsibility for payment of charges.
I agree to keep my account in good standing with this office.
I agree to let this office know if I change my address.
I understand that I will contact tis office immediately whenever I am experiencing finan-cial difficulties or unusual circumstance which may make it difficult for me to pay my bill in a timely manner.
I agree to set up a payment plan with this office if needed and to abide by the terms of that agreement.
I have read the items above, given them due consideration, and agree to them.
Certified American Board of Psychiatry and Neurology 1019 Remington Street, Fort Collins, CO 80525 I’d like to welcome you to our offices. I provide psychiatric assessment and treatment of adults and adolescents age 12 and older. What I consider are the four main factors in a person’s life: the medical, psychological, social and environmental factors. They are the “four legs” of the chair of a stable life, as it were. Weakness in one or more legs leads to problems with that chair (ie., one’s life) becoming unstable.
I am committed to providing the highest quality of care for my patients so they can get control of their life. My recommendations are based on the latest medical science re-search. I’ve summarized these and other things about my practice at my web site Good Day Journal.com and especially at gooddayjournal.com/harrisjensen.
Primary physician ________________________ Psychotherapist ________________________ Phone of psychotherapist ____________________ In a few short sentences, please summarize why you are seeking my assistance: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Date of birth _______________ Where born ________________________________ Parents supportive? ______________ Father’s occupation ____________________ Mother’s occupation ___________________ Brothers and ages _________________ Sisters and ages _____________________________ Close to parents?_______________ Brothers?____________ List last 3 jobs and why you left them ________________________________________ ____________________________________________________________________________________________________________________________________________ Legal problems as teen or adult ____________________________________________ Military history: branch ___________ Years service _________ Rank __________ Please list all your current medications. Include herbal supplements, vitamins, over the counter medications. Note mg per dose and doses per day. _____________________ ____________________________________________________________________________________________________________________________________________ Allergic to any medications? _______________________________________________ Prior psychiatrists (note name, city, state, diagnosis, medications) ____________________________________________________________________________________________________________________________________________ Prior psychiatric hospitalizations ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Recent stressful life events (circle all that apply): bad behavior of a family member, ex-cessive yelling by others, marriage, separation, divorce, pregnancy, new job, lost job, death of friend or family member, financial stress, health problems of friends or family member, sexual difficulties, retired, legal problems, traffic tickets, physical injury, illness, work problems, changed residence, large debts, lost house.
What is the most traumatic even you have ever experienced: ____________________________________________________________________________________________________________________________________________ Do you (circle what applies to this trauma) often think of this, have nightmares of it, feel edgy or on guard about it? Do you ever (circle what applies): feel sad, anxious, have poor sleep, poor concentra-tion, feel hopeless, feel helpless, have panic attacks.
Do you ever (circle what applies to you): eat large amounts of food, eat more than ex-pected, eat alone to hide how much you eat, think about food all day, try to cut back on eating but can’t, are aware of negative consequences of eating, eat to relieve stress.
Do you ever (circle what applies to you): induce vomiting, use laxatives or diuretics to lose weight, feel you weight too much or too little or the right amount? Are you trying to lose weight? How _______________________________________ Have you ever (circle what applies to you): had your thinking be confused so you lost track of your ideas, felt like people were watching you or wanted to hurt you, felt like your eyes were playing tricks on you, heard a voice or sound when no one or no thing was around to make the noise, seen things that were not there, heard a ringing in your ears? Have you ever had repeating thoughts or actions (circle what applies to you): to check things, doubt yourself, doubt others, evaluate others actions, evaluate yourself, check locks, check stoves, do things a certain way, count things, touch things in a ritual, about germs, about contamination, to wash hands repeatedly, to pull out hair, hoard or collect things you haven’t used in years? At night, do you have in your legs (circle all that apply): tingling, numbness, aching, rest-lessness, kicking at sheets, pins and needles feeling, tiredness, itching, uneasiness, pain, cramping in muscles, crawling or creeping sensation.
Are you ever afraid of: being teased or criticized, being the center of attention, meeting new people, seeing friends, leaving the house, meeting people in authority, making small talk at parties? How does this impact your life: _________________________.
Are you ever troubled by: fear of being judged, humiliated by something you’ve done, fear that someone will notice you are blushing or sweating or trembling or showing other signs of anxiety, knowing your fear is excessive. Impact of this anxiety on you and your life goals: ____________________________________________________________.
Past medications used: please circle all medications you’ve used and put a “p” by them if that was in the past, and a “c” by them if you are currently using them.
Insulin, cortisone, thyroid hormone, blood pressure medi- cine, migraine headache medicine, birth control pills, laxatives, steroids, weight loss medications.
Ambien, zolpidem, lunesta, sonata, proson, estazolam, dal- mane, flurazepam, doral, quazepam, restoril, temazepam, halcion, triazolam, chloral hydrate.
3. Medications for Attention Deficit Disorder: ritalin, methylphenidate, adderall, mixed amphetamine salts, concerta, vyvanse, dexedrine, straterra, provigil. Have you had people ask to “borrow” or use your medication? (Circle one) Yes No.
4. Mood stabilizers: Lithium, lithobid, eskalith, depakote, valproic acid, carbatrol, tegre-tol, carbamazepine, oxcarbazepine, trileptal, topomax, lamictal, lamotrigine, neurontin, depakene, verapamil, gabapentin, geodon, seroquel, risperdol.
prozac, fluoxetine, paxil, paroxetine, zoloft, sertraline, luvox, fluvoxamine, effexor, venla-faxine, trazadone, desyrel, anafranil, doxepine, nardil, pamelor, vivactil, remeron, sine-quan, surmontil, cymbalta, wellbutrin, bupropion, budeprion, zyban, lexapro, scitalo-pram, celexa, citalopram, parnate, nardil, phenelzine, tofranil, imipramine, asendin, elavil, amitryptilline, nortryptilline, norpramine, desipramine, protryptilline, maprotiline, serzone, tranylcypromine, clomipramine, amoxipine, ludiomil, mirtazipine, nefazadone.
6. Antipsychotic medications: haldol, abilify, aripirprazole, clozapine, zyprexa, olanzap-ine, prolixin, fluphenazine, stelazine, mesoridazine, moban, geodon, thorazine, chlor-promazine, navane, mellaril, risperdol, invega, risperidone, trilafon, trifluperazine, loxi-tane, molindone, seroquel, quetiapine, clozaril, thioridazine, perphenazine, serentil, loxapine. 7. Anti anxiety medications: ativan, lorazepam, valium, diazepam, klonopin, clonaze-pam, buspar, buspirone, atarax, chlordiazapoxide, restoril, oxazepam, reminyl, xanax, tranxene, paxipam, centrax, vistaril, alprazolam, librium, serax.
8. Other medications you have used:__________________________________.
Please list medical hospitalizations and operations you have had: ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Head injuries: Have you ever hit your head hard enough to be knocked out or dizzy or confused? Yes No Please tell me when this happened and how long you were affected by the injury: ____________________________________________________________________________________________________________________________________________ Have you or any blood relative ever had any of the following (circle all that apply and to the side of the item indicate if it was a “C” current problem or a “P” past problem,a nd if for a family member write who it was--mother, father, sister, brother, etc.
Depression, Bipolar affective disorder or manic depressive illness, migraine headache, alcoholism, alcohol related seizures, seizures, neurological problems, cataracts, ear infection, hay fever, worried, schizophrenia, attention deficit disorder (ADD), convulsions, stroke, glaucoma, eye or vision problems, tumor, chronic bronchitis, nervousness, anxiety, attention deficit hyperactivity disorder, obsessive compulsive disorder, panic attacks, verbally abusive, physically abusive.
Have you experienced any of the following (circle all that apply): Nausea, bloating, diarrhea of more than 10 days, double vision, vomiting, paralysis, weakness in a body part, can’t urinate, can’t get rid of all of urine, urinate more fre-quently, sexual indifference, sexual dysfunction, excessive menstrual bleeding, chest or heart pain, chest pressure, pain in urination, tuberculosis, fainting, vomiting, erectile problems, impaired balance, pain in abdomen or joint or limb, difficulty swallowing, loss of touch or pain sensation, blindness, double vision, irregular menstruation, seizures, pain during intercourse, other pain: _______________________, abnormal chest xray, impaired coordination, intolerance to several foods, ejaculatory problems, headaches, rectum pain, inability to talk normally, lump in throat, deafness, amnesia, back pain dur-ing menstruation.
Circle the following sleep problems if they have been happening: Trouble getting to sleep, staying asleep, waking with headaches or nasal congestion, sleepy during the day most days of the week, suddenly falling asleep during the day, sleepiness interfering with my daily activities, trouble waking up, sleep not refreshing. I sleep too much, too little, right amount.
Hours it takes to get to sleep__________, Hours of sleep per night ___________ Times waking up per night ___________, and hours it takes to sleep again _______.
If a man, my neck size is more than 17 inches. If a woman, my neck size is more than 16 inches. I wake in the night with a gasp. I wake with a choking sensation in the night. I snore. I gasp at night. I seem to stop breathing while I sleep. I snore most nights. My partner has complained about my snoring. The snoring can be heard in another room. The snoring forces people to sleep in another room. My partner complains I am restless in my sleep. I am restless when I sleep. I move or jerk when I sleep. I have hyperten-sion. My partner has noticed I seem more irritable or my personality has changed.
Amount of tobacco I smoke or chew per day: ________________________ Caffeine use per day: _____________ Cans of pop with caffeine per day ______ Substances I have used (circle all that apply): marijuana, amphetamines, LSD, mor-phine, ketamine, gamma hydroxy butyrate (GHB), cocaine, crystal methamphetamine, mushrooms, codeine, MDMA, Inhalants (paint, gas, white out, glue, other substances), speed, ecstasy, heroin, PCP.
I worry I might have a problem with alcohol or street drugs.
Someone else has worried I may have a problem with alcohol or street drugs.
I have tried to cut back on my use of alcohol or street drugs and was unable to.
I have been charged with driving while under the influence.
On an average day in the past week, this is the number of beers or drinks I consumed: ______ In the past year, this is the most drinks (or street drug use) I have used in a 24 hour pe-riod _____ I have had times when drinking alcohol or using street drugs when I later couldn’t re-member what happened.
I worry I may have a problem eating too much. Others are concerned about my over-eating. I have tried to cut back on my overeating, but failed. My overeating has caused other health problems (joint pain, back pain, hypertension, high cholesterol, heart dis-ease, diabetes, sleep apnea, social anxiety). The number of average sized meals I eat each day ________. I think about food much of the day. I comfort eat. I get defensive if other people ask me about my eating. I often eat alone. I often eat more than I in-tended.
Physical symptom survey (circle all that apply): I feel shaky, muscle tension, trouble swallowing, heart racing, dizzy, light headed, urinat-ing frequently, irritable, edgy, restless, startle easily, clammy hands, nausea, stomach pains, dry mouth.
Symptoms that come on suddenly (circle all that apply): Anxiety, fear of going crazy, nausea, abdominal discomfort, dizzy, faint, fear of dying, chest pain, chest pressure, short of breath, shaky hands.
Please complete the following statement by circling yes or no, whether an item applies to you, and note “in the last year” or if prior to that then circle “Lifetime.” Has there ever been a period of time when you were not your usual self and… 1. You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that it got you into trouble? In past year: yes or no. In lifetime: yes or no.
2. You were so irritable that you shouted at people or started fights or arguments? In past year: yes or no. In lifetime: yes or no.
3. You felt much more self-confident than usual? In past year: yes or no. In lifetime: yes or no.
4. You got much less sleep than usual and found that you really didn’t miss it or weren’t tired? In past year: yes or no. In lifetime: yes or no.
5. You were much more talkative or spoke much faster than usual? In past year: yes or no. In lifetime: yes or no.
6. Thoughts raced through your head or you couldn’t slow your mind down? In past year: yes or no. In lifetime: yes or no.
7. You were so easily distracted by things around you that you had trouble concentrating or staying on track? In past year: yes or no. In lifetime: yes or no.
8. You had much more energy than usual? In past year: yes or no. In lifetime: yes or no.
9. You were much more active or did many more things than usual? In past year: yes or no. In lifetime: yes or no.
10. You were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? In past year: yes or no. In lifetime: yes or no.
11. You were much more sexual than usual? In past year: yes or no. In lifetime: yes or no.
12. Spending money got you or your family in trouble? In past year: yes or no. In life-time: yes or no.
13. You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? In past year: yes or no. In lifetime: yes or no.
14. If you answered yes to question #13, what were the things you did? ___________ ______________________________________________________________________ 15. If you answered yes to two or more of the questions above, did these happen during the same period of time? ______________________________________________________________________ For men, circle if any applies: prostate trouble, difficulty urinating, sexual difficulties For women, circle any that apply to you: menstruating--yes or no, are your periods: regular, irregular, heavy, medium, light. Number of times pregnant:_________ Number of children: __________ Before menstrual periods do you have (circle what applies to you): worsening moods, mood changes, irritability, decrease in interest, decrease in energy, change in sleep patterns, marked increase in anxiety or tension, feeling not real, diffi-culty concentrating, increase or decrease in appetite, breast tenderness, headaches, joint or muscle pain, hot flashes or chills, trembling or shaking, sweating, tingling fin-gers.
______________________________________________________________________(On the next page is a survey for patients to complete after their first or second visit with the doctor to help facilitate good communication. Please keep it and bring it to your second visit with the doctor if you are taking any medication for your mood.) from Lars Kessing, et. al.,”Attitudes and beliefs among patients treated with mood stabi-lizers,” Clinical Practice and Epidemiology in Mental Health 2006, 2:8 (May 19).
Answer questions below with: mostly disagree (1), rather disagree (2), rather agree (3), mostly agree (4) 1. As long as you are taking mood stabilizers you do not really know if they are actually necessary _____ Please explain:________________________________________________________ 2. My doctor listens properly to what I think about mood stabilizers _____ Please explain:________________________________________________________ 3. When you have taken mood stabilizers over a long period of time it is difficult to stop taking them _____ Please explain:________________________________________________________ 4. With mood stabilizers my depressions and/or manic episodes disappear _____ Please explain:________________________________________________________ 5. My doctor has made me feel confident that mood stabilizers are the suitable treat-ment for me _____ Please explain:________________________________________________________ 6. When you take mood stabilizers you have less control over your thoughts and feel-ings _____ Please explain:________________________________________________________ 7. My doctor takes sufficient time to listen to my problems _____ Please explain:________________________________________________________ 8. You may take fewer tablets than prescribed on days when you feel better _____ Please explain:________________________________________________________ 9. Mood stabilizers can alter your personality _____ Please explain:________________________________________________________ 10. My partner agrees that mood stabilizers are a suitable treatment for my condition _____ Please explain:________________________________________________________ 11. Mood stabilizers correct the changes that occurred in my brain due to stress or prob-lems _____ Please explain:________________________________________________________ 12. My doctor has explained the causes of my disorder sufficiently _____ Please explain:________________________________________________________ 13. Your body can become addicted to mood stabilizers _____ Please explain:________________________________________________________ 14. Mydoctor takes sufficient time to discuss my emotional problems _____ Please explain:________________________________________________________ 15. My doctor has explained depression and mania sufficiently to me _____ Please explain:________________________________________________________ 16. My doctor shows sufficient consideration for my views and feelings about his treat-ment with mood stabilizers _____ Please explain:________________________________________________________ 17. Mood stabilizers help me to worry less about my problems _____ Please explain:________________________________________________________ 18. My partner agrees that depresive disorder or bipolar disorder is the correct diagno-sis of my condition _____ Please explain:________________________________________________________ 19. I receive sufficient psychological support and encouragement from my doctor _____ Please explain:________________________________________________________ 20. My doctor fully understands my condition _____ Please explain:________________________________________________________ 21. My doctor strongly emphasises that it is important to take the mood stabilizers regu-larly _____ Please explain:________________________________________________________ 22. My doctor is really interested in my problems _____ Please explain:________________________________________________________ 23. If you forget to take the mood stabilizer on a certain day, it is better to take an addi-tional dose the following day _____ Please explain:________________________________________________________ 24. Your body can become immune to mood stabilizers _____ Please explain:________________________________________________________ 25. My doctor listens properly when I tell him what it is like to be depressed _____ Please explain:________________________________________________________ 26. You may take more tablets than prescribedf on days when you feel more depressed _____ Please explain:________________________________________________________ 27. My doctor understands my feelings and thoughts in depression and mania perfectly _____ Please explain:________________________________________________________ 28. My doctor has explained properly about mood stabilizers, their action and side ef-fects _____ Please explain:________________________________________________________ 29. My doctor listens properly to what I consider to be the causes of my depression and or manias _____ Please explain:________________________________________________________ 30. Skipping a day now and again prevents your body from becoming immune to the mood stabilizers _____ Please explain:________________________________________________________ 31. I think my depression and or manic episodes are mainly due to factors associated with my personality _____ Please explain:________________________________________________________ 32. My emotional problems are solved by the mood stabilizers _____ Please explain:________________________________________________________ 33. Mood stabilizers make me stronger so I will be able to deal more efficiently with my problems _____ Please explain:________________________________________________________ Notes for additional information on above answers: __________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://gooddayjournal.com/system/files/New+Patient+Form1.pdf