PREVENTATIVE HEALTH QUESTIONNAIRE

Patient Name __________________ ______________________ ____________________ Gender □ M □ F Last First Middle

Preventive exams

PAP Smear (females 21-64) □ Yes □No Date: _______________ Physician: ___________________

Mammogram (females 40-69) □Yes □No Date: _______________ Physician: ___________________

Colonoscopy (≥ 50) □Yes □No Date: _______________ Physician: ___________________

Bone density test (females ≥ 65) □ Yes □No Date: _______________ Physician: ___________________

Glaucoma Screenings (≥ 65) □Yes □No Date: _______________ Physician: ___________________

Diabetic Eye Exam □Yes □No Date: _______________ Physician: ___________________

EKG □Yes □No Date: _______________ Physician: ___________________ Have you had any of the following vaccinations? Check all that apply, and specify when last received (mm/yyyy).

□ Yes □ No Influenza Date Last Given: ______________________

□ Yes □ No Pneumonia Date Last Given: ______________________

□ Yes □ No Tetanus Date Last Given: ______________________

□ Yes □ No Varicella (Zoster) Date Last Given: ______________________

Pharmacy Information (Local)

Name: ____________________________________ Phone: _____________________________ Zip: ____________

Pharmacy Information (Mail Order)

Name: ____________________________________ Phone: _____________________________ Zip: _____________

Have you completed a Living Will OR designated a Durable Power of Attorney for Health Care? □ Yes □ No

If yes, please provide a copy for your health care provider.

Do you have any religious or cultural beliefs that may impact your health care? □ Yes □ No

If yes, please describe.(ex. Blood products, etc)

___________________________________________________________________________________

Names and Phone Numbers for Health Care Providers (HCPs) from whom you are currently receiving care (or have

seen within the past 12 months), AND ANY Health Care Providers from whom you are obtaining prescriptions.

Physician: _____________________________________ Contact #:__________________________

Physician: _____________________________________ Contact #:__________________________

Physician: _____________________________________ Contact #:__________________________

AIM Center for Health and Wellness, PLLC. Page 2 of 2

During the past two weeks, have you felt down, depressed or hopeless? □ Yes □ No

During the past two weeks, have you felt little interest or pleasure doing things? □ Yes □ No

Do you have a history of smoking? □ Yes □ No If yes, ______ # packs per day X ______ for # years

Have you ever chewed tobacco? □ Yes □ No

Have you ever smoked pipes or cigars? □ Yes □ No If yes, how many cigars or bowls _____ per □Day □Week

Have you quit? If so, when? □ Yes □ No __________________________________________

Have you considered quitting? □ Yes □ No If yes, have you set a date to quit? □Yes □No

Have you tried quitting? □ Yes □ No If yes, what is the longest time period you quit smoking? ______

Do you have a history of alcohol use? □Yes □No

If yes, check all that apply: □ Beer □ Liquor □ Wine

If yes, specify _______ # drinks per □ Day □ Week □ Social

1 “drink” is equal to 12 oz. can of beer, 1.5 oz. liquor (80 proof) or 5 oz wine

Have you ever felt you should cut down on your drinking? □ Yes □ No

Have people annoyed you by criticizing your drinking? □ Yes □ No

Have you ever felt bad or guilty about your drinking? □ Yes □ No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? □ Yes □ No

Do you take aspirin? □ Yes □ No

Are you allergic to any medications? □ No □ Yes (Please List) _________________________________________

Please list all of the medications you are taking. Include over the counter medications, herbs & vitamins.

Medication Name Dose Frequency

(How often taken) Last taken

Signature of Patient/Legal Guardian: Date:

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name: ________________________________________________________________

Previous Name: ________________________________________________________________

Date of Birth: _________________________ Social Security #: __________________________

I request and authorize to release healthcare information of the patient named above to:

Address: AIM Center for Health and Wellness Phone: (214) 943-2249 1411 N. Beckley Ave. Fax: (214) 943-8213 Pavilion III, Suite 352 Dallas, Texas 75203

This request is for:

□ Howard Anderson Jr., M.D. □ Mollie Dorrough, M.D.

□ Kimberly Johnson, D.O. □ Keira Scanks, M.D.

This request and authorization applies to:

□ Healthcare information relating to the following treatment, condition, or dates:

________________________________________________________________________

________________________________________________________________________

□ All healthcare information

□ Other: __________________________________________________________________

________________________________________________________________________

Please send all requested information to the address or fax number listed above. Patient’s Signature: ______________________________________ Date Signed: ____________

THIS AUTHORIZATION EXPIRES 90 DAYS AFTER IT IS SIGNED. Thank you for your prompt attention.

PATIENT HIPAA CONSENT FORMOur Notice of Privacy practices provides information about how we may use and disclose protected health information about you.The notice contains a Patient Rights section describing your rights under the law. You have the right to review our notice beforesigning this consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting ouroffice.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment andhealthcare operations. You have the right to revoke this consent in writing, signed by you. However, such a revocation shall notaffect any disclosures we have already made in reliance to your prior consent. The practice provides this form to comply with theHealth Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice. The practice reserves the right to change the Notice of Privacy Policies. The patient may revoke this consent in writing at any time and all future disclosures will then cease.

I authorize that your office may contact me in the following manner (check all that apply):

□ Home Telephone ____________________ □ Work Telephone ____________________ □ Cellular Phone _____________________

Email:I give the AIM Center for Health and Wellness, PLLC. permission to email my laboratory results or clinical information to me at the listed email

address. I understand that email is not a secure route of delivering information and may be viewed by other individuals. I will not hold ACHWresponsible for any information pertaining to my health records being viewed by unauthorized individuals. Patient Initials ____________

NOTICE OF PRIVACY PRACTICESCONSENT TO THE USE & DISCLOSURE OF HEALTHCARE INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE

OPERATIONS AND ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I understand that as part of my healthcare, AIM Center for Health and Wellness originates and maintains health records describingmy history, symptoms, examination and test results, diagnosis, treatment, and plans for future care of treatment.

I understand that this information serves as: A basis for planning my care and treatment. A means of communication among the healthcare professionals who

contribute to my care. A source of information for applying my diagnosis and medical services information to my bill. Ameans by which a third-party payer can verify that services billed were actually provided. A tool for routine healthcareoperations such as assessing care quality and reviewing the competence of healthcare professionals.

I understand that I have the right to: Request restrictions as to how my information may be used or disclosed to carry out treatment, payment, or healthcare

operations (see below), and that AIM Center for Health and Wellness is not required to agree with the restrictionsrequested, in which case I will be notified. Revoke this consent in writing, except to the extent that the organization hasalready taken action in reliance thereon.

I request the following restrictions to the use of disclosure of my health information: (Please list below)__________________________________________________________________________________________________I have read the HIPPA CONSENT FORM and received a copy of AIM Center for Health and Wellness’ NOTICE OFPRIVACY PRACTICES.

Print Patient Name Signature of Patient/Legal Guardian Date

FOR OFFICE USE ONLY: We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices but:Individual refused to sign An Emergency precluded obtaining the acknowledgmentCommunication barriers precluded obtaining the acknowledgment Other____________________________________

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

Commercial Insurance

I hereby authorize the release of medical information necessary to file a claim with my insurance company and assignbenefits otherwise payable to me.

I understand I am financially responsible for any balance not covered by my insurance carrier. A copy of this signature isas valid as the original.

Signature of patient or guardian

Medicare Insurance

Beneficiary Medicare Number

I requested that payment of authorized Medicare benefits be made either to me or on my behalf AIM Center for Healthand Wellness, PLLC. for any service furnished to me by their physician. I authorize any holder of medical informationabout me to release to the Centers for Medicare and Medicaid Services and its agents any information needed todetermine benefits payable for related services.

Beneficiary Signature _________

Medicare Signature on File

I request that payment of authorized Medicare benefits be made on my behalf to AIM Center for Health and Wellness,PLLC. for services furnished me by their physician. I authorize any holder of medical information about me to release tothe Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine thesebenefits or the benefits payable for related services. I understand my signature requests that payment be made andauthorizes release of medical information necessary to pay the claim. If other health insurance is indicated on thestandard 1500 claim form or elsewhere on other approved claim forms, my signature authorizes releasing theinformation to the insurer or agency shown. AIM Center for Health and Wellness, PLLC. accepts the chargedetermination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance andnon-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

Patient’s Signature __________ Date _____________

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)DATE:NAME:Over the last 2 weeks, how often have you beenbothered by any of the following problems? Not at all Severaldays More thanhalf thedays Nearlyevery day(use "ⁿ" to indicate your answer) 0 1 2 3Little interest or pleasure in doing things1. 0 1 2 3Feeling down, depressed, or hopeless2. 0 1 2 3Trouble falling or staying asleep, or sleeping too much3. 0 1 2 3Feeling tired or having little energy4. 0 1 2 3Poor appetite or overeating5. 0 1 2 3Feeling bad about yourself or that you are a failure orhave let yourself or your family down6. 0 1 2 3Trouble concentrating on things, such as reading thenewspaper or watching television7. 0 1 2 3Moving or speaking so slowly that other people couldhave noticed. Or the opposite being so figety orrestless that you have been moving around a lot morethan usual8. 0 1 2 3Thoughts that you would be better off dead, or ofhurting yourself9. add columns + +TOTAL:(Healthcare professional: For interpretation of TOTAL,please refer to accompanying scoring card). Not difficult at allIf you checked off any problems, how difficulthave these problems made it for you to doyour work, take care of things at home, or getalong with other people?10. Somewhat difficultVery difficultExtremely difficultCopyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc.A2663B 10-04-2005

Checklist of Activities of Daily Living (ADL)

MAJOR Funding FOR Caring for Your Parents is pROvided by the hARRAh’s FOundAtiOn. AdditiOnAl Funding pROvided by the CORpORAtiOn FOR publiC bROAdCAsting And publiC televisiOn vieweRs.

speCiAl thAnks tO the stAFF OF AARp publiCAtiOns FOR theiR geneROus AssistAnCe with this pROgRAM.

Caring for Your Parents is A kiRk dOCuMentARy gROup, ltd. pROduCtiOn FOR wgbh bOstOn.

pbs.org/caringforyourparents

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Check the level of function of each activity of daily living listed below. this will help you determine how much assistance an elder needs.

Function independent needs Help dependent does not do

Bathing

Dressing

Grooming

Oral Care

Toileting

Transferring

Walking

Climbing Stairs

Eating

Shopping

Cooking

Managing Medications

Using the Phone

Housework

Doing Laundry

Driving

Managing Finances

1411 N. Beckley Ave. ▪ Pavilion III, Suite 352 ▪ Dallas, Texas 75203 Phone: (214) 943-2249 ▪ Facsimile: (214) 943-8213

Do I Need a Test for PAD? Peripheral Arterial Disease (PAD) is a serious circulatory problem in which the blood vessels that carry blood to your arms, legs, brain, or kidneys, become narrowed or clogged. It affects over 8 million Americans, most over the age of 50. It may result in leg discomfort with walking, poor healing of leg sores/ulcers, difficult to control blood pressure, or symptoms of stroke. People with PAD are at significantly increased risk for stroke and heart attack. Answers to these questions will determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.

Name: _______________________________ Date: ______________

Please Circle

1. Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest?

Yes No

2. Do you experience any pain at rest in your lower leg(s) or feet? Yes No

3. Do you experience foot or toe pain that often disturbs your sleep? Yes No

4. Are your toes or feet pale, discolored, or bluish? Yes No

5. Do you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks)?

Yes No

6. Has your doctor ever told you that you have diminished or absent pedal (foot) pulses?

Yes No

7. Have you suffered a severe injury to the leg(s) or feet? Yes No

8. Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)?

Yes No

9. Have you ever smoked? Yes No

10. Have you previously had a stroke? Yes No

11. Do you have heart disease? Yes No

12. Do you have diabetes? Yes No

CLINICIAN SUPPORT MATERIALS

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please be honest.

Place an X in one box that best describes your answer to each question.

Questions 0 1 2 3 4

1. How often do you have a drink Never Monthly 2 to 4 2 to 3 4 or more containing alcohol? or less times a month times a week times a week

2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or more alcohol do you have on a typical day when you are drinking?

3. How often do you have 5 or more Never Less than Monthly Weekly Daily or drinks on one occasion? monthly almost daily

4. How often during the last year Never Less than Monthly Weekly Daily or have you found that you were not monthly almost daily able to stop drinking once you had started?

5. How often during the last year Never Less than Monthly Weekly Daily or have you failed to do what was monthly almost daily normally expected of you because of drinking?

6. How often during the last year Never Less than Monthly Weekly Daily or have you needed a first drink in monthly almost daily the morning to get yourself going after a heavy drinking session?

7. How often during the last year Never Less than Monthly Weekly Daily or have you had a feeling of guilt or monthly almost daily remorse after drinking?

8. How often during the last year Never Less than Monthly Weekly Daily or have you been unable to remem­ monthly almost daily ber what happened the night before because of your drinking?

9. Have you or someone else been No Yes, but not in Yes, during injured because of your drinking? the last year the last year

10. Has a relative, friend, doctor, or No Yes, but not in Yes, during other health care worker been the last year the last year concerned about your drinking or suggested you cut down?

Total

Note: This questionnaire (the AUDIT) is reprinted with permission from the World Health Organization. To reflect standard drink sizes in the United States, the number of drinks in question 3 was changed from 6 to 5. A free AUDIT manual with guidelines for use in primary care settings is available online at www.who.org.

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