06/24/2016North Georgia Healthcare Center

06/24/2016NORTH GEORGIA HEALTHCARE CENTER

6120 ALABAMA HWY

RINGGOLD, GA 30736

PATIENTS INFORMATION

NAME: (LAST) ______(FIRST) ______(MIDDLE) ______

SOCIAL SECURITY NUMBER: ______-______-______SEX: ______DATE OF BIRTH: ______

STREETADDRESS: ______

CITY: ______STATE: ______ZIP: ______E-MAIL ______

RACE: ______HISPANIC / NON-HISPANIC PUBLIC HOUSING RESIDENCE ______# IN HOUSEHOLD ______

INCOME LEVELS: [ ] $0 - $15,000[ ] $15,001 - $25,000[ ] $25,001 - $35,000

[ ] $35,001 - $45,000[ ] $45,001 - $55,000[ ] $55,001 - $65,000

[ ] $65,001 - $75,000[ ] $75,001 and above

MARITAL STATUS: ______STUDENT: ______SMOKER: ______VETERAN: ______

HOME PHONE: ______CELL PHONE: ______

WORK PHONE: ______EXT: ______

EMERGENCY CONTACT: ______PHONE: ______

PRIMARY INSURANCE INFORMATION

NAME OF INSURED: ______RELATIONSHIP: ______

INSURED DATE OF BIRTH: ______SEX: ______INSURED SSN: ______-______-______

INSURANCE COMPANY: ______POLICY NUMBER: ______

SECONDARY INSURANCE INFORMATION

NAME OF INSURED: ______RELATIONSHIP: ______

INSURED DATE OF BIRTH: ______SEX: ______INSURED SSN: ______-______-______

INSURANCE COMPANY: ______POLICY NUMBER: ______

Personal Medical History
Instructions: Please check the boxes in each category for conditions you have currently or surgeries and conditions you have had in your lifetime. Use the blank space below for adding conditions or surgeries not listed.

Current & Past Medical Conditions / Past Surgical History

Diabetes / Colon Cancer / Appendectomy / Hysterectomy
Heart Attack / Breast Cancer / Tonsillectomy / C-Section
Heart Failure / Lung Cancer / Cholecystectomy / Colon Bypass
High Blood Pressure / ProstateCancer / Hemorrhoid Removal / Heart Bypass
Bronchitis/COPD / Ovarian Cancer / Breast Biopsy / Other-List Below
Asthma / OTHER: / HOW MANY HOSPITAL/ER VISITS HAVE YOU HAD IN THE PAST 2 YEARS?
______
Seizure / 1.HIV
Liver Disease / 2.TB
Stroke / 3.Sickle Cell
Mental Trouble / 4.Kidney prob.
Other:
FAMILY MEDICAL HISTORY
Instructions: Please check the boxes indicating diagnoses that apply to immediate family members.
Mother:_____Deceased
_____Age at death / Diabetes
Heart Attack
High Blood Pressure
Heart Failure
Emphysema / Lung Cancer
Colon Cancer
Breast Cancer
Ovarian Cancer
Others (list at right)
Father: ______Deceased
_____Age at death / Diabetes
Heart Attack
High Blood Pressure
Heart Failure
Emphysema / Lung Cancer
Colon Cancer
Breast Cancer
Ovarian Cancer
Others (list at right)
Siblings:______Deceased
_____Age at death
_____Age at Death / Diabetes
Heart Attack
High Blood Pressure
Heart Failure
Emphysema / Lung Cancer
Colon Cancer
Breast Cancer
Ovarian Cancer
Others (list at right)
SOCIAL HISTORY
Instructions: Please indicate your marital status and fill in your occupation. For habits, check the line next to the substance(s) you currently use or have used in the past and specify the types in the line to the right.
Marital Status: Single ______Married______
Divorced______Widowed ______ / Drugs: Heroin_____ Cocaine ______
Methamphetamine_____ Marijuana _____
Occupation: ______
Company: ______/ Alcohol: Liquor _____ Wine _____ Beer _____
Other: ______
Tobacco: Cigarettes ____ Cigars_____ Pipe_____
Smokeless ______Years Used: _____ / Drinks per week: ______
Date last used: ______

TO ALL PATIENTS

THE PRESCRIBING OF CONTROLLED MEDICATIONS IS ALWAYS AT THE DISCRETION OF THE PHYSICIAN.

DUE TO THEIR DOCUMENTAED POTENTIAL FOR ABUSE, PHYSIOLOGIC DEPENDENCE AND ADDICTION, THEY ARE USUALLY PRESCRIBED IN SMALL NUMBERS AND FOR SHORT PERIODS OF TIME. FOR THIS REASON, MULTI-REFILL PRESCRIPTIONS WILL NOT BE PROVIDED. HAVING BEEN ON CONTROLLED MEDICATIONS FROM A PREVIOUS PHYSICIAN IS NOT AN ACCEPTABLE REASON TO CONTINUE RECEIVING SUCH PRESCRIPTIONS. IF LONG-TERM USE IS ANTICIPATED OR DEEMED NECESSARY, REFERRAL TO A SPECIALIST IN PAIN MANAGEMENT, PSYCHIATRY, OR NEUROLOGY WILL BE REQUIRED.

OUR ABILITY TO PROVIDE MEDICAL SERVICES TO OTHERS DEPENDS ON OUR LEGAL AUTHORITY TO PRESCRIBE ALL CLASSES OF MEDICATIONS. IGNORING CURRENT FEDERAL AND STATE MEDICAL REGULATIONS WILL JEOPARDIZE THIS LEGAL AUTHORITY.

CLASS IICLASS IV

METHADONE (GENERIC)ZOLPIDEM (GENERIC)

MEPERIDINE (GENERIC) BRAND: AMBIEN

BRAND: DEMEROL, MEPERGANFLURAZEPAM (GENERIC)

HYDROMORPHONE (GENERIC) BRAND: DALMANE

BRAND: DILAUDIDTRIAZOLAM (GENERIC)

FENRTANYL (GENERIC) BRAND: HALCION

BRAND: DURAGESICESTAZOLAM (GENERIC)

MORPHINE (GENERIC) BRAND: PROSOM

BRAND: KADIAN, MsCONTIN,TEMAZEPAM (GENERIC)

ORAMORPH, MSIR, BRAND: RESTORIL

ROXANOL, AVINZALORAZEPAM (GENERIC)

OXYCODONE (GENERIC) BRAND: ATIVAN

BRAND: PERCOCET, OXYCONTIN,CLONAZEPAM (GENERIC)

ENDOCET, PERCODAN BRAND: KLONOPIN

METHYLPHENIDATE (GENERIC)CHLORDIAZEPOXIDE (GENERIC)

BRAND: RITAKUN, METADATE BRAND: LIBRIUM

DEXATROAMPHETAMINE (GENERIC)OXAZEPAM (GENERIC)

BRAND: ADDERALL, DEXEDRINE BRAND: SERAX

HYDROCODONE (GENERIC)CLORAZEPATE (GENERIC)

BRAND: VICODIN, VICOPROFEN BRAND: TRANXENE

LORATAB, LORCET, NORCO DIAZEPAM (GENERIC)

CLASS III BRAND: VALIUM

APLPRAZOLAM (GENERIC)

CODEINE: (GENERIC) BRAND: XANAX

BRAND: TYLENOL #2, #3, #4 SPECIAL CLASS IN GEORGIA

BUTALBITAL (GENERIC)

BRAND: FIORICET, ESGIC CARISOPRODOL (GENERIC)

BRAND: SOMA

I HAVE READ AND ACKNOWLEDGE THE ABOVE POLICY:

PATIENT SIGNATURE: ______DATE: ______

DATE OF BIRTH: ______

NORTH GEORGIA HEALTHCARE CENTER

6120 Alabama Hwy / P.O. Box 729 / Ringgold GA 30736

Phone: 706 935-6442 Fax: 706 935-6441

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name: / Date of Birth:
Previous Name: / Social Security #:
I request and authorize / to
release healthcare information of the patient named above to:
Name: / North Georgia Healthcare Center
Address: / P.O. Box 729
City: / Ringgold / State: / GA / Zip Code: / 30736
This request and authorization applies to:
 Healthcare information relating to the following treatment, condition, or dates:
 All healthcare information
 Other:
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
 Yes  No / I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
 Yes  No / I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.
Patient Signature: / Date Signed:
THIS AUTHORIZATION IS GOOD UNTIL REVOKED BY PATIENT IN WRITING.

PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION

TO FAMILY AND / ORFRIENDS

Name of Patient: ______Date of Birth: ______

North Georgia Healthcare Center (NGHCC) is authorized to release protected health information about the above named patient to the entities named below.

Entity to Receive Information. Initial each that is subject to this authorization.

Give information to following person(s):______

Description of Information to be released.

____Financial information.

____Family billing information.

____Information results from tests or x-rays.

____Medical information as follows:______

______

Other information as described: ______

______

Rights ofthe Patient

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to NGHCC.

I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing this authorization.

This Authorization shall be in force and effect until revoked by the patient or representative signing the Authorization.

______Date: ______

Signature of Patient or Representative

Description of Personal Representative’s Authority (attach necessary document)

PATIENT ACKNOWLEDGMENT OF UNDERSTANDING REGARDING

North Georgia Healthcare CenterPRIVACY PRACTICES

Patient’s Name: ______DOB: ______

SSN#:_____-____-______Previous Name(s):______

I understand the patient’s health information is private and confidential. I understand that NGHCCworks very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information.

I understand NGHCCmay use and disclose the patient’s personal information to help provide health care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission.

NGHCCpossesses a detailed document called “Notice of Privacy Practices.” It contains more information about the policies and practices protecting the patient’s privacy and it attached to this Acknowledgment. I understand that I have the right to read the “Notice” before signing this Acknowledgment.

NGHCCmay update this Acknowledgment and “Notice of Privacy Practices.” If I ask, NGHCCwill provide me with the most current “Notice of Privacy Practices.”

Within this “Notice of Privacy Practices” is a complete description of my privacy/confidentiality rights. These rights include, but aren’t limited to, access to my medical records; restrictions on certain uses; receiving an accounting of disclosures as required by law and requesting communication be by specified methods of communication or alterative action.

NGHCC’s established procedures help it meet its obligations to patients. These procedures may include other signature requirements, written acknowledgments, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs; etc. I will assist NGHCCby following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices.”

My signature below indicates that I reviewed a current copy of NGHCC’s “Notice of Privacy Practices.”

______Date: ______Time: ______

Signature

______

Relationship to patient if signed by anyone other than the patient,

(Parent, legal guardian, personal representative, etc.)

CONSENT TO TREATMENT/FINANCIAL RESPOSIBILITY

ALL PATIENTS MUST SHOW THEIR INSURANCE OR MANAGED CARE MEMBERSHIP CARD, AND CURRENT VALID STATE ISSUE PHOTO ID, SO THAT NGHCCMAY MAKE COPIES FOR THE PATIENT RECORD.

I CONSENT TO TREATMENT NECESSARY FOR THE CARE OF (patient name)

______.

______

Print Name Signature

OR, IF PATIENT IS A MINOR OR LEGALLY INCOMPETENT:

______

Print NameSignature of (parent or guardian)

FINANCIAL ARRANGEMENTS:

AT THE TIME OF SERVICE, YOU, THE PATIENT, ARE RESPONSIBLE FOR YOUR PERCENTAGE (I.E., “CO-PAYMENT”) PLUS ANY DEDUCTIBLE. IF YOUR INSURANCE COMPANY DOES NOT PAY WITHIN 90 DAYS FROM THE INITIAL DATE OF TREATMENT THEN THE FULL BALANCE AT THAT TIME IS YOUR RESPONSIBILITY.

I ACKNOWLEDGE FULL FINANCIAL RESPONSIBILITY FOR SERVICES RENDERED BY NGHCC FOR THE ABOVE NAMED PATIENT:

Signature: ______

Last NameFirstMiddle

Social Security#:______

Relationship to Patient: ______

Address: ______

City: ______State: ______Zip: ______

I AGREE TO PAY ALL REASONABLE ATTORNEYS’ FEES, INTEREST, PREJUDGMENT COLLECTION COSTS AND LITIGATION COSTS IN THE EVENT NGHCC FAILS TO RECEIVE PAYMENT IN FULL FOR THE COSTS OF MY MEDICAL TREATMENT. _____ (Initial)

ALL ACCOUNTS ARE DUE AND PAYABLE NO LATER THAN NINETY (90) CALENDAR DAYS FROM DATE OF SERVICE. I HEREBY AGREE TO A FINANCE CHARGE OF ONE (1%) PERCENT PER MONTH, (12% PER YEAR), ON ALL PAST DUE ACCOUNTS. _____ (Initial)

I FURTHER AUTHORIZE AND DIRECT THAT INSURANCE PAYMENTS SHALL BE MADE DIRECTLY TO NGHCC. _____ (Initial)

I READ AND FULLY UNDERSTAND THE ABOVE CONSENT & ACKNOWLEDGMENT OF TREATMENT CONDITIONS, FINANCIAL RESPONSIBILITY, RELEASE OF MEDICAL INFORMATION, AND INSURANCE AUTHORIZATION. _____ (Initial)

______

Signature Date

6120 Alabama Hwy, Ringgold GA30736CARDIOVASCULAR RISK QUESTIONNAIRE

P: 706-935-6442

NAME: ______EMAIL ADDRESS: ______

ADDRESS: ______

PHONE # :______DOB: ______Please Circle : MALE or FEMALE

CARDIOVASCULAR DISEASE: THE NUMBER ONE KILLER

Cardiovascular Disease is the biggest cause of death in the United States, with one person dying from it every 53 seconds. That’s over 597,000 people per year dying from heart attacks, strokes and blood clots.

WHAT IS CARDIOVASCULAR DISEASE?

Cardiovascular disease is the accumulation of fat in the arteries. This fat can cause blood clots to form and if large enough can completely block a blood vessel. When a clot blocks a blood vessel that is feeding the heart, part of the heart will die. This is called a heart attack. If a clot blocks a blood vessel connected to the brain, part of the brain will die, and this is called a stroke.

WHAT CAUSES CARDIOVASCULAR DISEASE?

Most people know that high cholesterol and blood pressure contribute to your risk of a heart attack. Knowing your cholesterol level and blood pressure is an important step in reducing your risk. However 50% of people who have heart attacks don’t have high cholesterol or high blood pressure. There are other important factors that can increase your risk of cardiovascular disease. You may have risk factors which haven’t been measured by your doctor. For example you may be under stress, not doing enough exercise, have poor immune function or be eating too much sugar. These are just a few of the many factors that may cause cardiovascular disease.

HOW DO I REDUCE MY RISK OF CARDIOVASCULAR DISEASE?

To reduce your risk of cardio0vascular disease you need to know what may be putting you in danger and what you can do about it. This questionnaire will help identify your risk of cardiovascular disease and allow you and your healthcare provider to decide on the most appropriate dietary changes, lifestyle changes or supplements to help you maintain a healthy heart and blood vessels.

PLEASE CIRCLE THE FOLLOWING ANSWERS TO THE QUESTIONS

FAMILY HISTORY:

How many hospital/ER visits have you had in the past 2 years? ______

Has anyone in your family had a heart attack or die suddenly before the age of 60? YES NO

Has a physician ever told you that you had a heart attack or have angina? YES NO

Has a physician ever told you that you had a stroke or have partially blocked blood flow to your head or legs? YES NO

Has a physician ever told you that you have diabetes? YES NO

Do you currently smoke? YES NO Amount per day? ______

How many times per week do you engage in aerobic exercises of a least 30 min duration?

NO REG EXERCISE ONCE PER WEEK TWICE PER WEEK THREE TO FOUR PER WEEK FIVE OR MORE PER WEEK

Indicate the kind of foods you usually eat:

HIGH SATURATED FAT FOODS: RED MEATS, WHOLE MILK, CREAM, BUTTER, CHEESE, CREAMY DRESSING, GRAVIES, FAST FOODS, DESSERTS, DEEP FRIED FOODS

LOW SAUTRATED FAT FOODS: SKIM MILK, LOW FAT DAIRY PRODUCTS, BREADS, CEREALS, FRUITS, VEGGIES, PEAS, BEANS, FISH, AND SKINLESS POULTRY

STAFF USE:

HEIGHT______WEIGHT ______BMI ______BLOOD PRESSURE ______PFT ______

LIPO/TRI ______GLU ______A1C______CBC ______CMP______

Tobacco Use Assessment Form

Name: ______Date: ______MR#: ______

1. Have you ever smoked cigarettes or used any other tobacco product?

_____YES _____NO

1. Do you currently smoke cigarettes or use any other tobacco product?

_____ YES _____NO – Date stopped ______

If you answered YES to questions 1 or 2, please answer the following:

Type of tobacco:______

Length of use (months or years):______

Amount used per day on average:______

1. Does anyone you live with or who is close to you smoke cigarettes or use other forms of tobacco?

_____ YES _____NO

Continue only if you answered YES to #2

1. How soon after you wake up do you smoke your first cigarette or use other forms of tobacco?

_____ within 30 minutes

_____ more than 30 minutes

1. How interested are you in stopping smoking or stopping use of other forms of tobacco?

_____ not at all

_____ a little

_____ some

_____ very

1. If you decided to quit smoking or using other forms of tobacco completely during the next 2 weeks, how confident are you that you would succeed?

_____ not at all

_____ a little

_____ some

_____ very

1. Have you ever intentionally quit smoking/using other forms of tobacco for 24 hours or longer?

_____ YES

_____ NO

In the past year? _____ YES _____ NO

In the past month? _____YES _____NO

Since the last visit? _____YES _____NO

Patient Health Questionnaire - 2 for MR#______

Over the last 2 weeks, how often have you been bothered by either of the following? (use a " " to indicate your answer) / Not at all / Several days / More than half the days / Nearly every day

1. Little interest or pleasure in doing things

1. Feeling down, depressed, or hopeless

Are you wanting a pregnancy or prevent a pregnancy? ____ wanting ____ prevent

Do you want this visit to be confidential? ____yes ____no

What form of prevention have you used in the past or are currently using?

Female sterilization ______Hormonal Implant _____ 1-Month hormonal injection _____
3-Month hormonal injection _____ Oral contraceptive _____ Contraceptive patch _____
Vaginal ring _____ Cervical cap or diaphragm _____ Contraceptive sponge _____
Female condom _____ Spermicide - used alone _____ Abstinence _____ Male condom _____
Withdrawal or other method _____ Rely on Male Method Vasectomy _____
FAM or LAM - Fertility awareness or lactational amenorrhea method _____
No method Pregnant/seeking pregnancy _____ Unknown/Not reported _____
Have you had any sexually transmitted disease or testing? _____ yes _____ no ______when?
Chlamydia _____ Gonorrhea _____ Syphilis _____
Have you ever had an HIV test? _____ yes _____ no ______when?
PAIN MANAGEMENT/CONTROLLED SUBSTANCE AGREEMENT
PATIENT: ______DOB:______

• The purpose of this Agreement is to prevent misunderstandings about certain medicines you will be taking for pain management or controlled substance such as anti-anxiety medication (Example-Valium, Xanax) or ADD/ADHD medications. This is to help both you and your doctor to comply with the law regarding controlled pharmaceuticals.

______PT INITIALS

• I understand this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this Agreement.

______PT INITIALS

• Because these medicines have the potential for abuse or diversion, strict accountability is necessary.

MEDICATION(S) ______
______

• I understand if I break this Agreement, my doctor will stop prescribing this pain-control medications/controlled substances.

______PT INITIALS

• I agree to notify my doctor of any and all pain medications or prescriptions I have received from other providers (effective from date of this agreement and ongoing). Such notification should occur by next business day following receipt of prescription. If I fail to alert my doctor I understand I may be discharged from the practice. ______PT INITIALS

• I understand at some point my doctor may wean me partially or totally from narcotics if he/she determines that, in the long run, this is likely to be in my best interests. In such situations other meds or therapies will likely be suggested as part of my new treatment plan. I agree to respect my doctor's opinion in such circumstances and comply with the new treatment plan.

______PT INITIALS

• I understand if I am suspected of diverting or distributing my pain medications/controlled substances, my doctor will immediately cease prescribing these medications. In this case, my doctor will be required to comply with local state and/ or federal reporting requirements and investigation.

______PT INITIALS