New Patient Intake FormPlease fill out the forms below and submit them at least 48 hours before your scheduled appointment. Date MM DD YYYY Name * First Name Last Name Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Best Phone (###) ### #### Second Phone (###) ### #### Email * Date of Birth * MM DD YYYY Gender * Male Female Transgender Non-binary/non-conforming Prefer not to respond Marital Status * Person or party responsible for payment of patient account * Patient/Guarantor Information: (complete only if someone other than the patient is financially responsible) Address of responsible party * INSURANCE INFORMATION Primary Insurance Name * Phone Number (###) ### #### Mailing Address * Policyholder's Name * First Name Last Name Date of Birth * MM DD YYYY Policy ID # * Group # * Secondary Insurance Name Phone Number (###) ### #### Mailing Address Policyholder's Name First Name Last Name Policy ID # Group # Emergency Contact * First Name Last Name Relationship to you * Phone Number * (###) ### #### MEDICAL HISTORY QUESTIONNAIRE In the assessment of the presence of attention or learning problems it is essential to know some of your medical background. What were the problems that caused you to seek consultation now? * If applicable: How did you start investigating whether you have ADD/ADHD? * By whom were you referred? * First Name Last Name Date of Birth * MM DD YYYY Age * Occupation * Current Height and Weight * Have you had any recent change in weight? * Yes No Do you have any current medical problems? * Yes No, I do not have any active medical problems. If yes, please list your current medical problems below as well as the recommended treatment you have received List all medications and their dosages you are currently taking (include all prescriptions and over-the counter medications such as antihistamines, decongestants, etc.) * If you have taken medication for Attention Deficit Hyperactivity Disorder now or at any time in the past, please list what medications, the dose (if you remember it), and any benefits or side effects * Have you ever been hospitalized or had surgery? If yes, please list problems below as well as the date of your hospitalization or surgery: Have you ever had a heart problem [high blood pressure, angina, irregular heartbeats, heart attack]? If yes, please give details: Do heart problems run in your family? * Have you ever had an EKG? If yes, when and what were the results? Have you ever had glaucoma [increased pressure in the eye]? * Yes No Have you ever had serious injury to your eye? * Yes No Do you wear corrective lenses? * Yes No If so, when was your last eye exam? NEUROLOGICAL HISTORY Have you ever had seizures? * Yes No If yes, please give details: Have you ever had trauma to your head that caused a loss of consciousness? * Yes No If yes, please give details: Have you ever had encephalitis [infection of the brain]? * Yes No Have you ever had a tic, unusual movements of your body, or Tourette's syndrome? * Yes No If yes, please give details: Name of your neurologist (if applicable): First Name Last Name Address of your neurologist (if applicable): Are you or either of your parents adopted? * Yes No If yes, please specify: Please give an estimate of your usual caffeine intake per day. * Cups of coffee/day Cups of tea/day Caffeinated colas, Mountain Dew, etc. /day Do you currently smoke? If yes, how many packs per day and how many years? Do you snore (Ask a bed partner to be sure)? * Yes No If yes, do you: Snore constantly Snore for a minute, then quiet for a minute, then snore, then quiet Snore only on your back Fall asleep easily during the day Are you right-sided, left-sided, or ambidextrous when you: * Write RT LT AMB Throw RT LT AMB Kick RT LT AMB Swing a bat or racket RT LT AMB Sight a camera or bow and arrow RT LT AMB Do you know of any allergic reactions you have had to medications? * Please list medication and reaction FOR WOMEN What birth control method do you rigorously use? Do you have a history of strong mood changes just before your menstrual period begins? Yes No If yes, are your menstrual cycles: Regular Irregular Is the onset of symptoms: Abrupt Gradual Is the ending or offset of symptoms: Abrupt Gradual ACADEMIC HISTORY How far did you go in school? * Were there any grades you had to repeat? * Were there any subjects that you could not do no matter how hard you tried? * Yes No If yes, which ones? Have you ever had formal IQ testing? * Yes No If yes, when and do you know your scores? MENTAL HEALTH HISTORY Have you had counseling or psychiatric consultation in the past? * Yes No If yes, when? With whom? What did you work on? Have you ever had a period of depression that lasted more than 2 weeks? * Yes No If yes, please describe what your depression(s) is like: Select all that apply Low energy, motivation Didn't care about anything Worry, indecision Uncharacteristically irritable Social withdrawal Unable to experience pleasure Loss of appetite Sleep disturbance Crying spells Sadness Poor memory Hopelessness Is the onset of your depressive symptoms typically: Triggered by events Gradual over a period of days to weeks Sudden, in a matter of seconds Looking back on your life, how old were you when you first got depressed? How long do your periods of depression typically last? Do you recall periods in which you experienced the opposite kind of mood...energetic, positive, productive, decreased need for sleep, the feeling of great well being or that there was nothing you could not do? * Yes No If yes, how long did it last? 1/2-day 1-day 2 days More than 4 days How often do you have such "high" periods? Do you have family members with Major Depression? * Yes No If yes, whom? Do they get any treatment? Do you have family members with Bipolar Disorder? * Yes No If yes, whom? Do they get any treatment? Do you have persistent worry or anxiety? * Yes No Do you have thoughts that bother you or make you anxious and that you can't get rid of regardless of how hard you try? * Yes No Do you have a tendency to keep things extremely clean or to wash your hands very frequently, more than other people you know? * Yes No Do you check things over and over to excess? * Yes No Do you have to straighten, order, or tidy things so much that it interferes with other things you want to do? * Yes No Do you worry excessively about acting or speaking more aggressively than you should? * Yes No Do you have great difficulty discarding things even when they have no practical value? * Yes No Do you find that you count things [ceiling tiles, words, money, etc] when you get anxious or bored? * Yes No Are you superstitious, have lucky or unlucky numbers, habits, etc.? * Yes No Have you ever, at any time in your life, excessively used or abused alcohol and/or drugs? * Yes No If yes, what and when? Do you have any genetic relatives who have had trouble with alcohol and/or drugs? * Yes No If yes, who? Have you ever had a blackout while drinking? * Yes No Do you now or have you in the past attended A.A., N.A., or some other 12-Step group? Is there anything else you think would be important to know about you? ADHD SCREENING CHECKLIST This checklist inquiries about lifelong behaviors. Answer "Yes" only if the particular trait or behavior has consistently impaired your functioning as long as you can remember. If you have the tendency to say “sometimes”, say “no” instead. Name * First Name Last Name For your entire life have you consistently had trouble paying attention to details or made careless errors in your work? * Yes No Have you had a lifelong difficulty concentrating on tasks which you find boring or uninteresting to you? * Yes No Do you often daydream or not seem to listen when people speak to you directly? * Yes No For your entire life have you consistently had difficulty finishing projects you've started? (Do you have a lot of half-finished projects around the home or office?) * Yes No Do you have difficulty organizing your work or become disorganized if not strictly following a plan or list? * Yes No Do you procrastinate or put off undesirable tasks until the last possible moment? * Yes No Have you always had a tendency to lose things necessary to accomplish your daily activities (For example, do you spend time almost every day searching for keys, tools, checkbook, etc.?) * Yes No Have you always been easily distracted by unimportant sounds and events around you? * Yes No Have you always been forgetful (ex: forget names, assignments, etc.)? * Yes No Have you always had difficulty sitting still or fidgeted excessively (even though you can now consciously control it)? * Yes No Have you always had difficulty staying seated? (e.g. Do you have difficulty sitting through a class, movie or church service?) * Yes No For as long as you can remember, have you been restless (e.g. unconsciously patted your foot, not been able to get comfortable sitting in a chair or lying in bed)? * Yes No For your entire life have you had significant difficulty relaxing or slowing down enough to do leisure activities quietly? * Yes No Have you always been described as “high energy” or “always on the go”? * Yes No Do you find that you talk excessively and/or often lose track of what you're saying in conversations? * Yes No For your entire life have you had a pattern of blurting out the answer before the questions have been completed? * Yes No Have you always been impatient or had difficulty waiting your turn in group situations (e.g., waiting in line at the grocery store or driving in traffic)? * Yes No Do you frequently interrupt or intrude on others (e.g.. butt into conversations, games, etc.)? * Yes No Have you always been very sensitive (significantly more sensitive than other people you know) to rejection, teasing, criticism, and frustration? * Yes No Do you have a hot temper for which you have no warning? * Yes No Do you have stand-up comedy tendencies or a “wacky/zany” sense of humor? * Yes No Do you find that you fall asleep when you sit still or suddenly get drowsy when boring tasks are prolonged? * Yes No For as long as you can remember have you had a great deal of difficulty waking up and being fully alert in the morning? * Yes No Have you been told that you move about excessively during sleep? * Yes No For your entire life have you consistently had trouble "turning off your mind" so you could fall asleep? * Yes No Do you "Hyperfocus"? * That is, do you have periods of activity during which you are so engrossed or involved in what you are doing that you are un-distractible by people or events around you and lose track of the passage of time? Yes No If yes, in what sort of activities do you Hyperfocus? Reading Computer/Internet Gardening Artistic Activities Games/Sports Other ADHD SCREENING CHECKLIST FOR FAMILY This form is to be completed by a parent, sibling or spouse. DO NOT leave blank. This checklist inquiries about lifelong behaviors. Answer "Yes" only if your family member has had the particular trait consistently as long as you can remember. If you do not know or don’t remember, enter a question mark (?). Name of Patient * First Name Last Name Your Relation to Patient * For their entire life has your family member consistently had trouble paying attention to details or made careless errors in their work? * Yes No Have they had a lifelong difficulty concentrating on tasks which they find boring or uninteresting? * Yes No Do they often daydream or not seem to listen when people speak to them directly? * Yes No For their entire life have they consistently had difficulty finishing projects they’ve started? (Do they have a lot of half-finished projects around the home or office?) * Yes No Do they have difficulty organizing their work or become disorganized if not strictly following a plan or list? * Yes No Do they procrastinate or put off undesirable tasks until the last possible moment? * Yes No Have they always had a tendency to lose things necessary to accomplish their daily activities (For example, do they spend time almost every day searching for keys, tools, checkbook, etc.?) * Yes No Have they always been easily distracted by unimportant sounds and events around them? * Yes No Have they always been forgetful (ex: forget names, assignments, etc.)? * Yes No Have they always had difficulty sitting still or fidgeted excessively (even though they can now consciously control it)? * Yes No For as long as you can remember, have they been restless (e.g. unconsciously patted their feet, not been able to get comfortable sitting in a chair or lying in bed)? * Yes No For their entire life have they had significant difficulty relaxing or slowing down enough to do leisure activities quietly? * Yes No Would they always be described as “high energy” or “always on the go”? * Yes No Have they always talked excessively and/or often lost track of what they’re saying in conversations? * Yes No For their entire life have they had a pattern of blurting out the answer before the questions have been completed? * Yes No Have they always been impatient or had difficulty waiting their turn in group situations? (e.g., waiting in line at the grocery store or driving in traffic)? * Yes No Do they frequently interrupt or intrude on others (e.g.. butt into conversations, games, etc.)? * Yes No Have they always been very sensitive (significantly more sensitive than other people you know) to rejection, teasing, criticism, and frustration? * Yes No Do they have a hot temper for which they have no warning? * Yes No Do they have stand-up comedy tendencies or a “wacky/zany” sense of humor? * Yes No Do they have a habit of falling asleep when they sit still or suddenly get drowsy when boring tasks are prolonged? * Yes No For as long as you can remember have they had a great deal of difficulty waking up and being fully alert in the morning? * Yes No Do they have a tendency to move about excessively during sleep? * Yes No For their entire life have they consistently had trouble "turning off their mind" so they could fall asleep? * Yes No Do they "Hyperfocus"? * That is, do they have periods of activity during which they are so engrossed or involved in what they are doing that they are un-distractible by people or events around them and lose track of the passage of time? Yes No If yes, in what sort of activities do you Hyperfocus? Reading Computer/Internet Gardening Artistic Activities Games/Sports Other Line CONSENT AND DISCLOSURE I understand and agree that all communication between my physician and me is held in confidence unless: 1. I authorize release of information with my signature. 2. My physician is ordered by a court to release information. 3. Child or elder abuse is reasonably suspected. 4. My physician believes that there is imminent risk of my harming an identifiable third party or myself. I understand that in the latter three cases the physician is required by law to inform legal authorities and/or potential victims. Initials * Date * MM DD YYYY Privacy Policy Because we take the protection of your protected health information (PHI) very seriously, we take every reasonable measure to protect it: 1. Your office visits are private and all notes taken are kept in locked storage. 2. All electronic prescribing systems are password protected and encrypted. 3. All emails are sent only to the address you designate and apart from your email address, only contain the PHI you choose to share. I will never ask for PHI, including medication information. Your information will never be sold and will only be shared with your permission. Initials * Date MM DD YYYY FINANCIAL POLICY I UNDERSTAND AND AGREE THAT FULL PAYMENT IS DUE AT THE TIME OF SERVICE and that this practice does not carry balances for any patient. Acceptable forms of payment are cash, check or credit card. • Responsibility for payment for services to a dependent child rests with the custodial parent who seeks treatment. • I understand and accept that Brendon Pardington PA-C is not a member of any managed care panel. As a courtesy to patients Brendon Pardington PA-C will provide billing statements and completed claim forms based on information that I have provided. I understand, however, that it is my responsibility to verify coverage and to obtain all necessary preauthorization of services required by my insurance carrier. I understand and accept that I am personally responsible for payment of the entire bill at the time of service regardless of the decisions of my insurance company. Initials * Date * MM DD YYYY I understand and accept that Brendon's hourly rate is $200 per hour: The Initial Intake Appointment usually takes between 90 minutes to 2 hours. • Costs between $300 - $400. The 30-minute follow-up Med Check Appointments (avg of every 3 months): • Cost $100 per 30 minutes. Initials * Date * MM DD YYYY I understand and accept that Brendon Pardington PA-C has set aside time especially for my care and, therefore, I will pay for all missed appointments and appointments not canceled with 24 hour notice. I understand that my insurance carrier will not be billed for missed or canceled appointments and that they will be my sole financial responsibility. Signature * Date * MM DD YYYY Thank you!
