3. ECP

3. Comprehensive Evaluation and Wellness Questionnaire
*

First Name Last Name
Date of Birth *

Month Day Year
Date
My appointment is with: *
Appointment date: *

Month Day Year
Date
Audit C
Audit-C Score:
PHQ-9
PHQ-9 Score:
Social Determinants of Health
Social Determinants of Health Score:
Medication Issues
What would you like to discuss with your provider today? *
Since you last saw the doctor, have you had any changes in any of the following areas? *

No New Symptoms Constipation Diarrhea Chest Pain Shortness of breath Numbness or tingling Weight gain Weight loss Mole Rash Joint pain Back Pain Anxiety Depression
Marital Status *

Married Partnered Single Separated Divorced Widowed
How many people live at home with you? *
Who lives with you? *

spouse/partner no one else (live alone) kids/grandkids other parents
Employment status *

Employed Retired Student Unemployed
What is your occupation? *
Since your last visit with our office, were you admitted to the hospital? *

No Yes
Please list details for all recent admissions: *
Since your last visit to our office, have you had any new testing performed? *
Please add details for all tests performed *
Since your last visit to our office, have you developed any new allergies or had a bad reaction to a medication or food? *

No Yes
Please add all new allergies: *
Since your last visit to our office, have you seen a specialist *

No Yes
Please list all specialists you have visited recently: *
Since your last visit to our office, have you had any vaccinations? (shots) *
Please list all vaccinations *
Since your last visit to our office, have you started any new prescribed medications, over-the-counter medications, herbal medications or vitamins? *

No Yes
Please list each new medication *
Has anything changed with the health of your family members? (including parents, siblings, or children) *

No Yes
Please explain: *
If you smoke or chew tobacco or vape, have you thought about quitting? *

	No	Yes
Has anyone been concerned about your drinking of alcohol or use of drugs?
Do you have a gun in the home?
Have you had sex with more than one partner within the past year?
Have you ever been emotionally or physically abused by your partner or someone important to you?
Do you find it difficult keeping your balance or have you fallen recently?
Do you have difficulty controlling your bladder, leaking or getting to the bathroom on time?

Medications
How often did you miss taking one or more of your medications in the last 2 weeks? *

Never Almost never Occasionally Frequently I do not take any medication

	No	Yes
Are you unsure or confused about what your medications are for?
Are you unsure or confused about how or when to take your medications?
Are you unsure or confused about why you need to take your medications?
Do you have any medications you cannot afford?
Do you have trouble getting your medications due to the inability to get to the pharmacy or have them delivered?
Do you have concerns or questions about your medication side effects?
Do you have difficulty taking medicine the way you are instructed?

Other Issues Affecting Your Health

	No	Yes
In the past year, was there a time when you could not afford to see a doctor?
Are you worried at times you cannot get your medicine due to expenses?
Do you ever eat less because there is not enough food?
Are you worried that in the next few months you may not have housing?
Do you feel your safety is threatened in your home?
In the past year, have you had a hard time paying your utility bills?
Do you feel like it is a hardship to obtain household supplies?
Do you have any problems with access to transportation to get to your medical appointments?
Do you need a translator to communicate with your provider?
Do you have difficulty learning about your medical condition from the information given to you or what is told to you?
Do you miss having people around you?

Do you receive enough support from family and friends? *

Always Usually Sometimes Never
How confident are you that you can control and manage most of your health problems? *

Very Somewhat Not very confident Not applicable
In the past 12 months, how often did you get an appointment in the amount of time you felt was appropriate? *

Always Usually Sometimes Never
In the past 12 months, how satisfied are you with the care or treatment you received in this office? *

Very Somewhat Not very satisfied Not applicable
Depression Screening (PHQ-9)

In the last 2 weeks how often have you had: *

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure than normal in doing things
Feeling down, depressed or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or feeling that you are a failure or that you have let yourself or family down
Trouble concentrating on things such as reading the newspaper or watching TV
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 in some way

Alcohol Screening
Did you have a drink containing alcohol in the past year? *

No Yes
How often did you have a drink containing alcohol in the past year? *

Never Monthly or less 2 - 4 times a month 2 - 3 times a week 4 or more times a week
How many drinks did you have on a typical day when you were drinking in the past year? *

1 or 2 3 or 4 5 or 6 7 to 9 10 or more
How often did you have 6 or more drinks on one occasion in the past year? *

Never Less than monthly Monthly Weekly Daily or almost daily
HIPAA PRIVACY AUTHORIZATION FORM

NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.

Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)

Please list names and relationships of all persons that you authorize Ninth Street Internal Medicine Associates to release your medical information to during the course of your care:

First Name  Last Name    Relationship
First Name Last Name   Relationship
First Name Last Name  Relationship

I hereby authorize all medical sources to release and disclose the following protected health information to:

NINTH STREET INTERNAL MEDICINE ASSOCIATES

805 Locust Street

Philadelphia, PA 19107

Phone: 215-440-8681

Specific Information to be disclosed:

Entire Medical Record
Only period of events from:   Please describe
Other:   Please describe

The information for which I’m authorizing disclosure will be used for the following purpose:

Further Medical Care
Personal use
Other:  Please describe


Important Information About Your Rights:

I understand that my records are protected under the Health Insurance Portability and Accountability Act, Federal Privacy Act, P.L. 93-575, the Federal Alcohol and Drug Abuse Act, P.L. 92-282, the Pennsylvania Mental Health Procedures Act, 1976 and the Pennsylvania Confidentiality of HIV Related Information Act, and therefore cannot be disclosed without my written consent unless otherwise provided for in the regulations. Under the Mental Health Act, this authorization expires one (1) month from the date of my signature. Under the Federal Alcohol and Drug Abuse Act, this authorization shall become void ninety (90) days from the date of my signature. In addition, I understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereon) at any time by written, dated communication to the Ninth Street Internal Medicine and/or that my consent expires under the circumstance above. I understand that once copies of my information are provided, NSIM cannot prevent re-disclosure by the recipient. I understand that any information disclosed in response to this request will NOT include information related to my treatment for AIDS/HIV, psychiatric care/treatment, treatment for drug/alcohol, unless I specifically consent to release of this information by checking any or all the boxes below:

AIDS/HIV Information
Psychiatric Care/Treatment
Treatment for Drug and Alcohol use/abuse
Name

First Name Last Name DOB
Should be Empty:

3. Comprehensive Evaluation and Wellness Questionnaire

Medications

Other Issues Affecting Your Health

Depression Screening (PHQ-9)

Alcohol Screening