Jemsek Specialty Clinic – Appointment or Phone Consult Preparation Form

Appointment Date: ______/ ______/ ______

Name: ______Date of Birth: ______/ ______/ ______

Pharmacy: ______Pharmacy Phone #: ______

Lab: ______Lab Phone #:______

Other Facility: ______Phone #: ______

Dear Patient,

To help prepare for your upcoming appointment, please use this form as a resource for organizing your top questions and concerns. In order to optimize your medical management, it is essential to list all prescription and over-the-counter agents you are currently using. Please list medication, dose and timing (ie: Amoxicillin 500mg 2 three times per day; Phenergan 25mg 1 twice daily, as needed for nausea). Please make sure you include medication and supplements managed by other members of your medical team. It is important to list how you are currently taking the medications, as labels on the pill bottles often don’t provide enough information. In addition, clear information enables us to identify medication errors. The Jemsek Specialty Clinic works hard to coordinate medication management to improve your treatment and maintain your safety. The questions below will also help to ensure that we are updated on any recent changes or events affecting your health and medical care. Please use additional pages, as needed.

For an in-person visit: Please bring this completed form to your scheduled appointment time or send the completed form as an attachment in a message through patient portal “Submit Information for Your Appointment” option.

For a phone consult: Please send this form to the clinic at least two business days (48 hours) prior to your scheduled appointment. This form is required for your phone consult. We also ask that you please provide payment for your phone consult at least 48 hours in advance. You may submit your payment online through the patient portal or call our billing desk at 202-955-0003, ext 204.Failure to submit this completed form and payment two business days (48 hours) prior to your appointment will result in the cancellation of your appointment. Once this form has been completed, you may send it to the clinic one of the following ways:

  1. You may log into the patient portal and send the completed form as an attachment in a message through the “Submit Information for Your Appointment” option.
  2. You may fax it directly to the clinic at 1-866-457-0397, Attn: Front Desk.

Please make sure all labs, procedures, or tests that were ordered have been completed before your appointment.

  1. What are your top three concerns at this time (i.e. sleep, pain, etc.)?
  1. Have you had any changes or experienced any new signs/symptoms since your last appointment? Have you had any medical encounters or procedures (i.e. ER visit, MRI, etc.) since your last appointment?
  1. Are there additional questions/concerns you would like to address with your provider during your appointment?
  1. If your appointment is a phone consult, what is the best phone number to reach you at?
  2. What are your current medications/supplements? Have there been any changes in your medications/supplements since your last appointment?

Please find below a list of commonly used medications or supplements. If you are taking one of these, write the dose/strength of the pill/capsule/tablet and the directions for use.

For Example: Zofran 4 mg 2 tabsthree times per day

Medication / Strengthof Capsule/Tablet
(ie. mg, ml) / How many tablets/capsules per dose / How many times per day do you take this dose?
(And # of times per week if applicable)
Antibiotics
Artemisinin/Artemesia
Ceftin (Cefuroxime)
Cipro (Ciprofloxacin)
Coartem (Artemether/Lumefantrine)
Dapsone
Diflucan (Fluconazole)
Doxycyline
Flagyl (Metronidazole)
Leucovorin (Folinic Acid)
Levaquin (Levofloxacin)
Malarone (Atovaquone/proguanil)
Mepron Suspension (Atovaquone)
Minocin (Minocycline/hydrochloride)
Omnicef (Cefdinir)
Pyrimethamine (Daraprim)
Rifabutin (Mycobutin)
Septra DS or Bactrim (Sulfamethoxacole/Trimethoprim)
Tindamax (Tindazole)
Zithromax (Azithromycin)
Lactoferrin
Xylitol
Antinausea
Phenergan (Promethazine)
Zofran (Ondansetron)
Endocrine
Armour Thyroid (Thyroid)
Cortef (Hydrocortisone)
Cytomel (Liothyronine)
Synthroid (Levothyroxine)
Testosterone (specify route)
Medication / Strengthof Capsule/Tablet
(ie. mg, ml) / How many tablets/capsules per dose / How many times per day do you take this dose?
(And # of times per week if applicable)
Neurotropics/Psychotropics
Adderall
Ativan (Lorazepam)
Cymbalta (Duloxetine)
Diamox (Acetazolamide)/Potassium (Klor-Con)/Vitamin C
Effexor (Venlafaxine)
Lamictal (Lamotrigine)
Lexapro (Escitalopram)
Lyrica (Pregabalin)
Marinol (Dronabinol)
Mobic (Meloxicab)
Neurontin (Gabapentin)
Neurotropic Cream
Nuvigil (Armodafinil)
Provigil (Modafinil )
Risperdal (Risperidone)
Tegretol (Carbamazepine)
Topamax (Topiramate)
Trileptal (Oxcarbazepine)
Valium (Diazepam)
Vyvance (lisdexamftamine dimesylate)
Xanax (Alprazolam)
Zonegran (Zonisamide)
Sleep
Klonopin (Clonazepam)
Deep Sleep (OTC)
Melatonin (OTC)
Remeron (Mirtazapine)
Seroquel IR (Quetiapine IR)
Seroquel XR (Quetiapine XR)
Trazodone (Desyrel, Oleptro)
Xyrem (Sodium Oxybate)
Supplements
ALA (Alpha Lipoic Acid)
Burbur
DHEA (OTC)
Fish Oil (Omega-3's)
Iron
L-Carnitine (Acetyl-L-Carnitine/ALCAR)
Medication / Strengthof Capsule/Tablet
(ie. mg, ml) / How many tablets/capsules per dose / How many times per day do you take this dose?
(And # of times per week if applicable)
Supplements Continued
L-Glutamine
Magnesium (Malate)
Methyl B12 (indicate route)
Methyl Folate (Deplin or OTC)
Multivitamin
NAC (N-Acetyl L-Cysteine)
Nattokinase NSK-SD (Nattozyme)
Niacin
Potassium (Klor-Con)
Probiotics (bacterial) specify brand
Resveratrol
Saccharomyces (Boulardii)
ThermaTabs (Sodium)
Vitamin C
Vitamin D3
Over the Counter (OTC)
Advil (Ibuprofen)
Aleve (Naproxen)
Benadryl (Diphenhydramine)
Prilosec (Omepraxole)
Tylenol (Acetaminophen)
Zyrtec (Cetirizine)
Blood Thinners
Aspirin
Coumadin (Warfarin)
Lovenox
Xalreto (Rivaroxaban)
Pradaxa (Dabigatran etexilate)