Adult Information Form IDENTIFYING INFORMATIONPatient Name*Other Preferred NameAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail* Date of Birth*Emergency Contact*Emergency Contact Phone*Referred By*Do you plan on submitting claims to your insurance company for reimbursement?* YES NO If yes, please note that you are responsible for requesting Superbills from your visits to allow you to file your own claim with your insurance company.CONSENT TO TREATMENTI HEREBY CONSENT TO EXAMINATION AND TREATMENT AS DEEMED NECESSARY BY PATRICIA A. HESS, M.D. I hereby request that payment of authorized benefits be made on my behalf and hereby assign the benefits payable for physician services to the physician if she chooses to accept the assignment. I hereby authorize Patricia A. Hess, M.D. PA to furnish Patient Health Information concerning my relevant medical history to any insurance company who will be paying the claim.Signature*Date of Signature* MM slash DD slash YYYY PRIVACY NOTICEIn accordance with the Health Insurance Portability and Accountability Act, patients of Patricia A. Hess M.D. PA are entitled to and afforded the rights to privacy regarding their health-related information as set forth under applicable law. Patricia A. Hess M.D. PA will strive to ensure that patient information is used only for purposes authorized by the patient and as otherwise required by law. Upon request, we can provide you with a complete copy of our Privacy Policies. Additionally, Patients have a right to review their medical records and furnish comments to their records during normal business hours, upon providing reasonable advance notice.Signature*Date of Signature* MM slash DD slash YYYY PRESCRIPTION HISTORY CONSENTAgree that Patricia A. Hess, M.D. PA may request and use my prescription medication history from other healthcare providers and E-Forse (Florida's Prescription Drug Monitoring Program) for treatment purposes.Signature*Date of Signature* MM slash DD slash YYYY GOOD FAITH ESTIMATEDr. Patricia Hess, MD PA Mailing Address: 2725 NW 38th St Gainesville FL 32605 Email: info@patriciahessmd.com Phone: 352-224-5220 NPI: 1669669826 TIN: 273120009 PRIMARY SERVICE - Virtual Outpatient Visit $350 - First Evaluation with Dr. Patricia Hess, MD (99205-95) - 1 visit. Payment will be collected 1 day before visit $190 - First Follow Up or visits needing 40 minutes (99214-95) - 1-3 visits annually, depending on need. Payment collected the morning of the appointment. $135 - 20 Minute Follow Ups (99213-95) - 4-10 visits annually, depending on need. Payment collected the morning of the appointment.Office Policies I certify that all of the information listed on this form is true and correct. I understand that this is a fee for service, to be paid on the day of services rendered; a credit card must be obtained and kept on file for all charges. No shows and all cancellations with less than 24 hours notice will result in the following No Show Fees: - First Evaluation - Full fee will be collected - 40 Minute Appointments - $75 the first time and then full fee for all subsequent visits - 20 Minute Appointments – $50 the first time and then full fee for all subsequent visits Any patient 10 minutes late for a scheduled appointment will be considered a No Show resulting with the No Show Fee listed above and will need to be rescheduled. If this account is assigned to an attorney, collection agency, or small claims court, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collection. I understand that I am financially responsible for all charges, whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure payment. Signature*Date of Signature* MM slash DD slash YYYY Signature of Parent or Guardian (If patient is a minor)*Date of Signature* MM slash DD slash YYYY Highest Grade Level of Education CompletedDegree AchievedPRESENTING PROBLEMPlease describe the problems which have led you to seek treatment or evaluation.*What do you believe to be the most important factor(s) causing the problem?*When did you first notice these problems?Have there been any family changes (new baby, death, divorce, etc.) which may be related to these problems? Please explain:Have you ever been seen for counseling or therapy? Yes No As an outpatient (clinic, private, etc.)Name of doctor or therapistPhoneAddressFor how long?DatesReason for treatmentName of doctor or therapistPhoneAddressFor how long?DatesReason for treatmentHave you been evaluated with psychological tests, e.g. intelligence testing or personality evaluation? Yes No Name of doctor or therapistPhoneType of testingDatesAs an inpatient (in a hospital, residential treatment center, etc)Facility nameAddressFor how long?DatesReason for treatmentName of doctor or therapistPhoneSignature*Date MM slash DD slash YYYY Medical HistoryFamily doctorPhone MM slash DD slash YYYY Have you ever been in the hospital for medical problems? Yes No If YesHospital Name, City, and stateDatesReason For HospitalizationHospital Name, City, and stateDatesReason For HospitalizationHospital Name, City, and stateDatesDo you have any serious or chronic physical or medical condition (diabetes, etc.)? Yes No If Yes, please explainAre you taking any prescribed/non-prescribed medications?* Yes No If Yes, please list belowMedication NameTreatmentMedication NameTreatmentMedication NameTreatmentDo you have any medication allergies* Yes No If Yes, please list belowAllergyReactionAllergyReactionAllergyReactionHave you ever been injured in any accidents or falls? Yes No If Yes, please list belowIncidentInjuryAgeIncidentInjuryAgeIncidentInjuryAgeHave you suffered any complications of illnesses or accidents (high fever, convulsions, coma, etc)? Yes No If Yes, please explainDo you now, or have you ever in the past, used alcohol or other drugs on a regular basis? Yes No If Yes, please list belowType of drugHow often?How much in each episode?Type of drugHow often?How much in each episode?Type of drugHow often?How much in each episode?Do you now, or in the past, smoked cigarettes/cigars/pipes on a regular basis? Yes No If Yes, please list belowType of tobaccoHow often?How many years?Type of tobaccoHow often?How many years?Have you experienced difficulty with any of the following? (Please check all that apply.)Headaches Yes Current N/A Seizures Yes Current N/A Numbness/tingling in extremities Yes Current N/A Difficulty maintaining balance Yes Current N/A Fainting or black out spells Yes Current N/A Ringing in ears Yes Current N/A Difficulty with hearing Yes Current N/A Difficulty with vision Yes Current N/A Shortness of breath Yes Current N/A High blood pressure Yes Current N/A Trouble with swallowing Yes Current N/A Diarrhea, chronic Yes Current N/A Weight gain or loss in the past year Yes Current N/A Loss of appetite Yes Current N/A Preoccupation with weight gain or loss Yes Current N/A Eating problems Yes Current N/A Itching of skin Yes Current N/A Skin rash Yes Current N/A Hyperactivity Yes Current N/A Crying spells Yes Current N/A Feeling angry often Yes Current N/A Mood swings Yes Current N/A Nervousness Yes Current N/A Problems/ difficulty with memory Yes Current N/A Problem with thinking clearly Yes Current N/A Chronic fatigue or weakness Yes Current N/A Problems with attention/concentration Yes Current N/A Depression and anxiety Yes Current N/A Sudden behavior or personality change Yes Current N/A Sleeping problems Yes Current N/A Impulsive; act without thinking Yes Current N/A Problems with sexual behavior Yes Current N/A Physical assault/abuse Yes Current N/A Problems with sexual behavior Yes Current N/A Sexual assault / abuse Yes Current N/A Anxiety / panic episodes Yes Current N/A Financial problems Yes Current N/A Occupational problems Yes Current N/A Learning problems Yes Current N/A Family/relationship difficulties Yes Current N/A Social relationship problems Yes Current N/A Unusual experiences Yes Current N/A Disturbing thoughts Yes Current N/A Suicide attempts Yes Current N/A Suicidal thoughts Yes Current N/A Problems with the law Yes Current N/A Pregnancy Information (if applicable)Were there any physical or emotional difficulties during pregnancy with your children or during your mother’s pregnancy with you? Yes No If Yes, please explainWere you or were any of your children premature? Yes No If premature, please give the number of weeks early.SelfChildrenWere there any of the following complaints? Mother taking medication or drugs? (Specify)Can choose one or multiple Long labor Forceps delivery Breech birth Eclampsia Cesarean Section OtherWere there any immediate complications following delivery of your children or with you? Yes No If Yes, please explainNumber of pregnanciesNumber of miscarriagesWeight of largest child at birthFamily InformationHas anyone in the family (including grandparents) been treated for a mental health problem? Yes No If Yes, please explainHas anyone in the family (including grandparents) had a substance abuse problem? Yes No If Yes, please explainList individuals that live in your home.Family HistoryFatherAgeState of HealthOccupationMotherAgeState of HealthOccupationSpouseAgeState of HealthOccupationBrothersAgeState of HealthOccupationNameAgeState of HealthOccupationSistersAgeState of HealthOccupationNameAgeState of HealthOccupationSonAgeState of HealthOccupationNameAgeOccupationNameAgeState of HealthOccupationDaughterAgeState of HealthOccupationAgeState of HealthOccupationNameAgeState of HealthOccupationWho in your family has had:Cancer Father Mother Sister Brother Grandmother Grandfather Children Other Tuberculosis Father Mother Sister Brother Grandmother Grandfather Children Other Allergies & Asthma Father Mother Sister Brother Grandmother Grandfather Children Other Strokes Father Mother Sister Brother Grandmother Grandfather Children Other Nervous Breakdowns Father Mother Sister Brother Grandmother Grandfather Children Other Suicide Father Mother Sister Brother Grandmother Grandfather Children Other Convulsions/epilepsy Father Mother Sister Brother Grandmother Grandfather Children Other Headaches Father Mother Sister Brother Grandmother Grandfather Children Other Diabetes Father Mother Sister Brother Grandmother Grandfather Children Other Arthritis Father Mother Sister Brother Grandmother Grandfather Children Other Heart Attack Father Mother Sister Brother Grandmother Grandfather Children Other High Blood Pressure Father Mother Sister Brother Grandmother Grandfather Children Other Kidney Stones Father Mother Sister Brother Grandmother Grandfather Children Other Ulcers Father Mother Sister Brother Grandmother Grandfather Children Other Other Father Mother Sister Brother Grandmother Grandfather Children Other I understand that this information will be used in my evaluation and will be included in my records.Signature*Date* MM slash DD slash YYYY CLICK HERE TO PRINT THIS FORM BEFORE SUBMITTING
