7. NCP with Medwell Forms

Name *

First Name Last Name

Date of Birth *

Date

My appointment is with: *

Appointment date: *

Date

Audit C

Audit-C Score:

PHQ-9

PHQ-9 Score:

Social Determinants of Health

Social Determinants of Health Score:

Medication Issues

Falls Risk

Pain Screening

ADLs

Urinary Incontinence

Flu Shot

Contact Info: *

Email Address:

example@example.com

Preferred method of contact *

Patient Portal Access

Our practice offers a HIPAA secure patient portal for our patients that will allow you to send and receive non-urgent secure messages to our office regarding your health records, laboratory tests, and appointments, as well as give you access to view portions of your medical record online.

*We will respond to these email communications within 2 business days. Please note that urgent medical issues requiring same day attention continue to require that contact our office by phone. In addition, if you rarely check your email, please do not sign up for the patient portal.

Would you like to be set up with access to our patient portal?

Yes, please sign me up for the patient portal No, do not sign me up

Gender

Sexual Orientation

Marital Status:

Spouse/Partner's Name: *

Employment status

Employed Student Retired Unemployed

What is your occupation? *

Highest Education Level:

Please explain:

How many people live at home with you? *

Who lives with you? *

spouse/partner I live alone kids/grandkids parents Other

Emergency Contacts: *

Insurance: *

Guarantor Info: *

Pharmacy: *

CONSENT TO OBTAIN COMPLETE PRESCRIPTION MEDICATION HISTORY

Our practice utilizes an integrated tool within our electronic medical records system that provides us with up-to-date information about all prescriptions given to you by all of your providers. It will allow us to view all medications dispensed to you, and help us to prevent adverse medication interactions. Please be assured that this is for the NSIM providers only and you may opt out of this feature at any time.

By clicking below you certify that you have read and understand the scope of your consent and that you authorize access to your prescription medication history

I authorize NSIM to view my external prescription history

*If you do not wish to take advantage of this service, please check below:
I wish to opt out of this service

Other / Previous Physicians: (enter "None" if not applicable) *

What would you like to discuss with your provider today? *

Do you experience any of the following symptoms often or on a regular basis?: *

Do you have any of the following health conditions? (select all that apply) *

Please provide additional details for the conditions you selected above: *

Surgical History: Please list all previous surgeries; (enter "None" if not applicable) *

Please list each medication, over-the-counter medication, vitamin or supplements you currently take: (enter "None" if not applicable) *

Allergies: List all allergies to medication, food, or other agents (smoke, pollen etc.) *

Please list all screening tests you have completed: *

Immunization History: List all vaccinations you have received *

Family Medical History: *

Please indicate if any of the above relatives (or any other relatives) have any of the following:

Blood clotting/bleeding disorder Heart attack/stroke Cancer Mental illness/substance abuse

Please list the type(s) of cancer: *

Breast cancer Ovarian cancer Colon cancer Prostate cancer Melanoma Other

Smoking and tobacco *

Please provide more details about your smoking, vaping, and tobacco use: *

Illicit drug use *

Please provide more details for your drug usage: *

*

	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?

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

No Yes

If yes, were you injured? *

No Yes

*

	No	Yes
Do you have difficulty with dizziness or problems with balance?
Do you avoid doing things due to the fear of falling?
Do you have things in your house which might cause you to fall?

*

	Almost Never	Occasionally	Frequently
How often does physical or emotional health interfere with your daily activities?
How often do you take the escalator over the stairs?
How often does pain interfere with your normal activities?

On a scale of 0 to 10, (ten being strongest) how much pain do you have on a daily basis? *

If you do have daily pain, where is the pain located? *

Approximately how many days each week are you physically active? *

0 - 1 days 2 - 3 days 4 or more days

How many days a week do you exercise? *

0 - 1 days 2 - 3 days 4 or more days

How many hours of sleep do you usually get each night? *

5 or less hours 6 - 7 hours 8 or more hours

*

	No	Yes
Do you need help eating, bathing, getting dressed, or getting around your home?
Do you need help preparing your own meals?
Do you need help doing your own housekeeping?
Do you need help with shopping?
Do you need help handling your own money?
Do you need help travelling by bus or taxi?
Do you need more help at home with your care or doing chores?

Do you drive a car? *

No Yes

If yes, do you have any difficulty driving? *

No Yes

When was your last dilated eye exam? *

*

	No	Yes
Do you have problems with your hearing?
Do you have problems with your memory?
Do you have trouble eating well?
Do you have trouble with your teeth or dentures?

Have you had a flu shot this year? *

No Yes

If not, do you want a flu shot? *

No Yes

Do you have a living will? *

No Yes

If yes, have you given us a copy? *

No Yes

*

	No	Yes
Is leaking of urine a problem for you?
Has urine leakage changed your activities or interfered with your sleep?

If urine leakage is a problem for you, would you be willing to try any of the following? *

	No	Yes
Medications
Bladder training exercises
Surgery

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?

*

	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

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

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

New Patient Evaluation and Medicare Annual Wellness Questionnaire

Falls Risk

Physical Activity and Pain

Activities of Daily Living

Other Health Issues

Bladder Control

Medications

Other Issues Affecting Your Health

Depression Screening (PHQ-9)

Alcohol Screening