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Solutions for Mindfulness Registration Form

Solutions For Mindfulness Registration Form

Today's Date:

Primary Care Physician:

Patient Information

Patient's Last Name:

First Name:

Middle Name:

Email:

Marital Status:

Is this your legal name?

Yes No

If not, what is your legal name?

( Former name )

Birth Date:

Age:

Sex:

Female Male

Street Address:

Social Security #:

Home Phone #:

P.O. Box

City:

State:

ZIP Code:

Occupation:

Employer:

Employer Phone #:

Choose clinic because/ Referred to clinic by

Other family members seen here

Insurance Information

Person responsible for bill:

Birth Date:

Address(if different):

Home Phone #

Occupation

Employer

Employer Address

Employer Phone #

Is this patient covered by insurance?

Yes No

Subscriber's Name:

Subscriber's Social Security #:

Birth Date:

Group #:

Policy #:

Co-payment:

Patient's Relationship to Subscriber:

Name of Secondary Insurance (if applicable):

In Case of Emergency

Name of Local Friend or Relative:

Relationship to Patient:

Home Phone #:

Work Phone #:

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or the insurance company to release any information required to process my claims.

Patient/Guardian Signature:

Date:

MEDICAL HISTORY

Have you ever been hospitalized medically?

Yes No

If yes, please list and describe: Why, when, where, and how long?

Have you ever had surgery?

Yes No

If yes, please list (surgery & year):

Current medical problems (if any):

History of Seizures?

Yes

History of Head Trauma?

Yes No

History of Thyroid Problems?

Yes No

History of Asthma?

Yes No

Current Medications (name and dosage):

Allergies?

Yes No

If yes, please describe (to what & reaction):

PRIMARY CARE PHYSICIAN

Name:

Phone #:

Fax #:

Permission to contact?

Yes No

How long have you been with him/her?

PERSONAL HISTORY

History of physical abuse?

Yes No

If yes, by whom?

History of sexual abuse?

Yes No

If yes, by whom?

Was it reported?

Yes No

Childhood History

Did you enjoy growing up?

Yes No

Describe the home atmosphere growing up:

Education/Job History

Highest education level:

History of special education?

Yes No

Are you working?

Yes No

If yes, current occupation:

If no, how do you currently support yourself?

Relationship/Sexual History

Relationship status:

Currently in a relationship Single Married Divorced Separated Widowed

Interested in:

Males Females Both

Are you currently sexually active?

Yes No

HIV Status:

Positive Negative Never Tested

Last test date (if tested):

Children? Yes No If yes, how many?

What is your current living situation?

Legal History

Have you ever been arrested?

Yes No

If yes, explain:

Have you ever been convicted for a crime/felony? Yes No

If yes, explain:

DUI/DWI? Yes No

If yes, when?

Religious Affiliation

Religious Affiliation:

None Yes

FAMILY HISTORY

Were you adopted?

Yes No

Are your parents:

Father

Name:

Age:

Circle one:

Living Deceased

Occupation:

Retired?

Yes No

Psychiatric history?

Yes No

If yes, describe (i.e. diagnosis, medications, etc.):

History of substance abuse?

Yes No

Mother

Name:

Age:

Circle one:

Living Deceased

Occupation:

Retired?

Yes No

Psychiatric history?

Yes No

If yes, describe (i.e. diagnosis, medications, etc.):

History of substance abuse?

Yes No

Siblings

Do you have any siblings?

Yes No

If yes, how many brothers and/or sisters?

Any siblings with psychiatric history?

Yes No

If yes, please describe:

Any siblings with a history of substance abuse? Yes No

If yes, please describe:

Any history of suicide in the family? Yes No

If yes, who & when?

Any history of suicide attempts in the family? Yes No

If yes, who & when?

Additional Comments:

Binge Eating Disorder Screener (BEDS-7)

Name:

Date:

Please tap in one box per row per column which best describes how your eating habits, exercising, or feelings about your eating, shape, or weight have affected your life over the past four weeks (28 days).

*Tap in the boxes for YES or NO for each question.

1. During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time ?

Yes

Note: If you answered "NO" to question 1, YOU MAY STOP. The remaining questions do not apply to you.

2. Do you feel distressed about your episodes of excessive overeating?

Yes

Within the past 3 months...

	Never or Rarely	Sometimes	Often	Always
3. During your episodes of excessive overeating, how often did you feel like you had no control over your eating, feel compelled to eat, or going back and forth for more food ?
4. During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?
5. During your episodes of excessive overeating, how often were you embarrassed by how much you ate?
6. During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?
7. During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?

Patient Health Questionnaire (PHQ-9)

Name:

Date:

Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. 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
9. Thoughts that you would be better off dead, or of hurting yourself in some way

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Hamilton Anxiety Rating Scale (HAM-A)

Name:

Date:

Below is a list of phrases that describe certain feelings people often have. Rate the patients by finding the answer which best describes the extent to which they have these conditions.

Item	Not Present	Mild	Moderate	Severe	Very Severe
1. Anxious mood (worries, anticipation of the worst, fearful anticipation, irritability)	Not Present	Mild	Moderate	Severe	Very Severe
2. Tension (feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax)	Not Present	Mild	Moderate	Severe	Very Severe
3. Fears (of dark, of strangers, of being left alone, of animals, of traffic, of crowds)	Not Present	Mild	Moderate	Severe	Very Severe
4. Insomnia (difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors)	Not Present	Mild	Moderate	Severe	Very Severe
5. Intellectual (difficulty in concentration, poor memory)	Not Present	Mild	Moderate	Severe	Very Severe
6. Depressed mood (loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing)	Not Present	Mild	Moderate	Severe	Very Severe
7. Somatic (muscular) complaints (pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone)	Not Present	Mild	Moderate	Severe	Very Severe
8. Somatic (sensory) complaints (tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensation)	Not Present	Mild	Moderate	Severe	Very Severe
9. Cardiovascular symptoms (tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, missing beat)	Not Present	Mild	Moderate	Severe	Very Severe
10. Respiratory symptoms (pressure or constriction in chest, choking feelings, sighing, dyspnea)	Not Present	Mild	Moderate	Severe	Very Severe
11. Gastrointestinal symptoms (difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation)	Not Present	Mild	Moderate	Severe	Very Severe
12. Genitourinary symptoms (frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence)	Not Present	Mild	Moderate	Severe	Very Severe
13. Autonomic symptoms (dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair)	Not Present	Mild	Moderate	Severe	Very Severe
14. Behavior at interview (fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc.)	Not Present	Mild	Moderate	Severe	Very Severe

ASRS Self-Report Assessment

Name:

Date:

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, select the box that best describes how you have felt and conducted yourself over the past 6 months.

	Never	Rarely	Sometimes	Often	Very Often
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?

Thank you! All forms have been submitted successfully. Our representative will get in touch soon.

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9 AM - 2 PM, Friday - Saturday
Closed, Sunday

Solutions For Mindfulness Registration Form

Patient Information

Insurance Information

In Case of Emergency

SELF-ASSESSMENT

CHIEF COMPLAINT

PATIENT PSYCHIATRIC QUESTIONNAIRE

PSYCHIATRIC HISTORY

Substance Use (Check all that apply)

MEDICAL HISTORY

Current Medications (name and dosage):

PRIMARY CARE PHYSICIAN

PERSONAL HISTORY

Childhood History

Education/Job History

Relationship/Sexual History

Legal History

Religious Affiliation

FAMILY HISTORY

Father

Mother

Siblings

Binge Eating Disorder Screener (BEDS-7)

Within the past 3 months...

BSDS / Bipolar Spectrum Diagnostic Scale

Patient Health Questionnaire (PHQ-9)

Hamilton Anxiety Rating Scale (HAM-A)

ASRS Self-Report Assessment

Open Hours