Adult Information FormIDENTIFYING 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. $125 - 20 Minute Follow Ups (99213-95) - 4-10 visits annually, depending on need. Payment collected the morning of the appointment.Office PoliciesI 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 visitsAny 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 NoAs 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 NoName 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 NoIf 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 NoIf Yes, please explainAre you taking any prescribed/non-prescribed medications?* Yes NoIf Yes, please list belowMedication NameTreatmentMedication NameTreatmentMedication NameTreatmentDo you have any medication allergies* Yes NoIf Yes, please list belowAllergyReactionAllergyReactionAllergyReactionHave you ever been injured in any accidents or falls? Yes NoIf Yes, please list belowIncidentInjuryAgeIncidentInjuryAgeIncidentInjuryAgeHave you suffered any complications of illnesses or accidents (high fever, convulsions, coma, etc)? Yes NoIf Yes, please explainDo you now, or have you ever in the past, used alcohol or other drugs on a regular basis? Yes NoIf 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 NoIf 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/ASeizures Yes Current N/ANumbness/tingling in extremities Yes Current N/ADifficulty maintaining balance Yes Current N/AFainting or black out spells Yes Current N/ARinging in ears Yes Current N/ADifficulty with hearing Yes Current N/ADifficulty with vision Yes Current N/AShortness of breath Yes Current N/AHigh blood pressure Yes Current N/ATrouble with swallowing Yes Current N/ADiarrhea, chronic Yes Current N/AWeight gain or loss in the past year Yes Current N/ALoss of appetite Yes Current N/APreoccupation with weight gain or loss Yes Current N/AEating problems Yes Current N/AItching of skin Yes Current N/ASkin rash Yes Current N/AHyperactivity Yes Current N/ACrying spells Yes Current N/AFeeling angry often Yes Current N/AMood swings Yes Current N/ANervousness Yes Current N/AProblems/ difficulty with memory Yes Current N/AProblem with thinking clearly Yes Current N/AChronic fatigue or weakness Yes Current N/AProblems with attention/concentration Yes Current N/ADepression and anxiety Yes Current N/ASudden behavior or personality change Yes Current N/ASleeping problems Yes Current N/AImpulsive; act without thinking Yes Current N/AProblems with sexual behavior Yes Current N/APhysical assault/abuse Yes Current N/AProblems with sexual behavior Yes Current N/ASexual assault / abuse Yes Current N/AAnxiety / panic episodes Yes Current N/AFinancial problems Yes Current N/AOccupational problems Yes Current N/ALearning problems Yes Current N/AFamily/relationship difficulties Yes Current N/ASocial relationship problems Yes Current N/AUnusual experiences Yes Current N/ADisturbing thoughts Yes Current N/ASuicide attempts Yes Current N/ASuicidal thoughts Yes Current N/AProblems with the law Yes Current N/APregnancy Information (if applicable)Were there any physical or emotional difficulties during pregnancy with your children or during your mother’s pregnancy with you? Yes NoIf Yes, please explainWere you or were any of your children premature? Yes NoIf 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 SectionOtherWere there any immediate complications following delivery of your children or with you? Yes NoIf 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 NoIf Yes, please explainHas anyone in the family (including grandparents) had a substance abuse problem? Yes NoIf 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 OtherTuberculosis Father Mother Sister Brother Grandmother Grandfather Children OtherAllergies & Asthma Father Mother Sister Brother Grandmother Grandfather Children OtherStrokes Father Mother Sister Brother Grandmother Grandfather Children OtherNervous Breakdowns Father Mother Sister Brother Grandmother Grandfather Children OtherSuicide Father Mother Sister Brother Grandmother Grandfather Children OtherConvulsions/epilepsy Father Mother Sister Brother Grandmother Grandfather Children OtherHeadaches Father Mother Sister Brother Grandmother Grandfather Children OtherDiabetes Father Mother Sister Brother Grandmother Grandfather Children OtherArthritis Father Mother Sister Brother Grandmother Grandfather Children OtherHeart Attack Father Mother Sister Brother Grandmother Grandfather Children OtherHigh Blood Pressure Father Mother Sister Brother Grandmother Grandfather Children OtherKidney Stones Father Mother Sister Brother Grandmother Grandfather Children OtherUlcers Father Mother Sister Brother Grandmother Grandfather Children OtherOther Father Mother Sister Brother Grandmother Grandfather Children OtherI 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
