Oluyemi Aina, M.D. · Oluyemi Aina, M.D. Joyce Mwaniki, MSN, PMHNP-BC 3140 Legacy Dr. Suite 710 •...

Oluyemi Aina, M.D. Joyce Mwaniki, MSN, PMHNP-BC

3140 Legacy Dr. Suite 710 • Frisco, Texas 75034 • Tel (214) 494 2131 • Fax (214)-494-2316 1601 N Travis Street, Sherman, Texas 75092 • Tel (903) 325-6556 • Fax (903) 868-0282

PATIENT INFORMATION: Patient Registration

Last Name: First Name: Middle Initial: Date of Birth: Social Security #: Marital Status: Single/Married/Divorced/Widowed Sex: Male [ ] Female [ ] Race: Ethnicity: Preferred Language: Mailing Address City: State: Zip: Phone Number: Home Cell Work Employed: [ ] Yes [ ] No Full Time Student: [ ] Yes [ ] No Disabled: [ ] Yes [ ] No Retired: [ ] Yes [ ] No Is the patient a minor? [ ] Yes [ ] No If Yes, Please fill out the information below: Parent(s)/Guardian(s) Name: Date of Birth: Social Security #: Mailing Address City: State: Zip: Phone Number: Home Cell Work May we contact you by phone for appointment reminders? [ ] Yes [ ] No Preferred Contact #: [ ] Home [ ] Work [ ] Cell

EMERGENCY CONTACT INFORMATION: Spouse’s Name: Phone #: Name: Relationship: Phone #: Name: Relationship: Phone #: Primary Care Physician: Phone #: Specialist Physician: Phone #: Specialist Physician: Phone #: Counselor/Therapist: Phone #:

PATIENT EMPLOYER INFORMATION: Name of Employer: Phone: Fax: Address: City: State: Zip:

INSURANCE POLICY INFORMATION: Primary Insurance: Subscriber ID#: Group#: Policy Holder’s Last Name: Policy Holder’s First Name: Policy Holder’s Date of Birth: Policy Holder’s Social Security #: Relationship to the Patient: Secondary Insurance: Subscriber ID#: Group#: Policy Holder’s Last Name: Policy Holder’s First Name: Policy Holder’s Date of Birth: Policy Holder’s Social Security #: Relationship to the Patient:

I certify that the information provided above is complete and accurate to the best of my knowledge.

Signature of Patient or Patient Representative Date



Authorization to Disclose Health Information Medical Records Release

Patient Name (Please print) Date of Birth

Social Security Number Phone Number

I HEREBY AUTHORIZE DISCLOSURE OF INFORMATION TO/FROM THE NAMED INDIVIDUALS OR ORGANIZATION(S) LISTED BELOW:

x I understand that incomplete forms will be null and void; no exceptions. x I understand that disclosure of my health information does not include mailing or faxing copies of my medical records; I must complete a medical records release

in order to have copies of my medical records mailed or faxed to the named individual(s) or organization(s). x I understand that specific information to be disclosed may include history of Drug or Alcohol Abuse or Mental Health Treatment, information concerning

communicable diseases such as Human Immunodeficiency Virus (HIV), and Immune Deficiency Syndrome (AIDS), laboratory test results, treatment progress, and any other such related information. This authorization will expire 1 year from the date of my signature.

x I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the patient is prohibited.

x I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself.

x I further authorize that a photocopy of this authorization is acceptable as an original. x I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by

federal HIPAA privacy regulations. x The practice will not condition my treatment, payment, and enrollment in a health plan or eligibility for benefits on whether I provide authorization for the

requested use or disclosure. I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to: Privacy Officer: 1601 N Travis Street, Sherman, Texas 75092 • Tel (903) 325-6556 • Fax (903) 868-0282

Print Patient Name Patient/Guardian Signature Date Relationship

Witness Signature Title Date

[ ] Release Other (Please specify): � DO NOT SPEAK/RELEASE INFORMATION TO ANYONE

Phone Number Relationship to Patient Full Name or Person/Organization/Physician’s Office [ ] Release all Health Information [ ] Release all Billing Information (including payments, collections, etc.)







Medical and Behavioral Health History

Patient First Name: Last Name: DOB: Why are you being seen today?

MEDICAL HISTORY Do you now or have you ever had: � Diabetes � Obstructive Sleep Apnea � Crohn’s disease � High blood pressure � Pneumonia � Colitis � High cholesterol � Pulmonary embolism � Anemia � Hypothyroidism � Asthma � Jaundice � Hyperthyroidism � Emphysema � Hepatitis � Cancer (type) � Stroke � Stomach or peptic ulcer � Leukemia � Epilepsy (seizures) � Rheumatic fever � Psoriasis � Food Allergies � Tuberculosis � Angina � Kidney disease � HIV/AIDS � Heart problems � Kidney stones

Other medical conditions (please list):

SURGERY HISTORY

Please list any surgeries you have had and the year they were done.

Do you have any medical problems that are not listed above?



Patient First Name: Last Name: DOB: Why are you being seen today?

BEHAVIORAL HEALTH HISTORY Do you now or have you ever had:

� ADHD/ADD (If Yes, at intake complete ADHD Checklist)

� Intellectual Disabilities � Sedative Dependence

� Panic Disorder & Agoraphobia

� Major Depressive Disorder (MDD) � Pseudobulbar Affect (PBA) (If Yes, at intake complete PHQ-9) (If Yes, at intake complete CNS-LS)

� Alcohol Dependence � Nicotine Dependence � Substance Abuse

� Anorexia � Obsessive Compulsive Disorder (OCD) (If Yes, at intake complete OCD/Y-Bocs Scale)

� Insomnia (If Yes, at intake complete Insomnia Questionnaire)

� Borderline Personality Disorder � Social Anxiety/Social Phobia (If Yes, at intake complete Social Interaction Anxiety)

� DMDD � Chronic fatigue ( if Yes, at intake

complete Fatigue severity Scale) � Bulimia Nervosa � Paranoid Schizophrenia

� Cannabis Dependence � Post-Traumatic Stress Disorder (PTSD)

� Delusional Disorder � Schizoaffective Disorder

� Bipolar and/or Mood Disorder (if Yes, at intake complete The Mood Disorder Questionnaire)

� Generalized Anxiety Disorder (GAD)

BEHAVIORAL HEALTH PRESCRIPTION HISTORY Please select all of the following that you have tried and FAILED: Anti-depressants � Prozac (fluoxetine) � Zoloft (sertraline) � Luvox (fluvoxamine) � Paxil (paroxetine) � Celexa (citalopram) � Lexapro (escitalopram) � Effexor (venlafaxine) � Cymbalta (duloxetine) � Wellbutrin (bupropion) � Remeron (mirtazapine) � Serzone (nefazodone) � Anafranil (clomipramine) � Pamelor (nortrptyline) � Tofranil (imipramine) � Trintellix (vortioxetine) � Elavil (amitriptyline) Mood Stabilizers � Valproic Acid � Tegretol (carbamazepine) � Lithium � Depakote (valproate) � Lamictal (lamotrigine) � Tegretol (carbamazepine) � Topamax (topiramate) Other medical medication (please list):

Antipsychotics/Mood Stabilizers � Seroquel (quetiapine) � Zyprexa (olanzepine) � Geodon (ziprasidone) � Abilify (aripiprazole) � Abilify Maintena Injection � Aristada Injection � Invega (paliperidone) � Invega Sustenna Injection � Invega Trinza Injection � Clozaril (clozapine) � Haldol (haloperidol) � Prolixin (fluphenazine) � Rexulti (brexpiprazole) � Risperdal (risperidone) � Saphris (asenapine) � Vraylar (cariprazine) Sedative/Hypnotics � Ambien (zolpidem) � Belsomra � Lunesta (eszopiclone) � Sonata (zaleplon) � Rozerem (ramelteon) � Restoril (temazepam) � Desyrel (trazodone)

ADHD medications � Adderall (amphetamine) � Adderall XR (amphetamine XR) � Concerta (methylphenidate) � Evekeo (amphetamine) � Focalin (dexmethylphenidate) � Procentra (dextroamphetamine) � Ritalin (methylphenidate) � Strattera (atomoxetine) � Vyvanse (lisdexamfetamine) � Zenzedi (dextroamphetamine) Anti-anxiety medications � Xanax (alprazolam) � Ativan (lorazepam) � Klonopin (clonazepam) � Valium (diazepam) � Hydroxyzine � Tranxene (clorazepate) � Buspar (buspirone) Substance/Alcohol Abuse � Suboxone (buprenorphine/naloxone) � Zubsolv (buprenorphine/naloxone) � Bunavail (buprenorphine/naloxone) � Subutex (buprenorphine) � Vivitrol (naloxone) Injection � Naloxone tablets � Campral (acomprosate) � Antause (disulfiram)



FAMILY HISTORY

IF LIVING IF DECEASED Age Health & Psychiatric Age(s) at death Cause

Father

Mother

Children

Grandparents

Aunts/Uncles

SYSTEMS REVIEW In the past month, have you had any of the following problems? GENERAL THROAT SKIN � Recent weight gain; how much � Frequent sore throats � Redness � Recent weight loss: how much � Hoarseness � Rash � Fatigue � Difficulty in swallowing � Nodules/bumps � Weakness � Pain in jaw � Hair loss � Fever NERVOUS SYSTEM � Color changes of hands or feet � Night sweats � Headaches BLOOD MUSCLE/JOINTS/BONES � Dizziness � Anemia � Numbness � Fainting or loss of consciousness � Clots � Joint pain � Numbness or tingling

� Muscle weakness � Memory loss PSYCHIATRIC � Joint swelling STOMACH AND INTESTINES � Depression Where? � Nausea � Excessive worries EARS � Heartburn � Difficulty falling/staying asleep � Ringing in ears � Stomach pain � Poor appetite � Loss of hearing � Vomiting � Frequent crying EYES � Yellow jaundice � Sensitivity � Pain � Increasing constipation � Thoughts of suicide / attempts � Redness � Persistent diarrhea � Stress � Loss of vision � Blood in stools � Irritability � Double or blurred vision � Black stools � Poor concentration � Dryness KIDNEY/URINE/BLADDER � Racing thoughts HEART AND LUNGS � Frequent or painful urination � Hallucinations � Chest pain � Blood in urine � Rapid speech � Palpitations Women Only: � Guilty thoughts � Shortness of breath � Abnormal Pap smear � Paranoia � Fainting � Irregular periods � Mood swings � Swollen legs or feet � Bleeding between periods � Anxiety � Cough � PMS � Risky behavior



SUBSTANCE USE

Age when first tried

this:

How much & how often

did you use this?

How many years did you use

this?

Last use?

Do you currently

use this?

ALCOHOL Yes □ No □

CANNABIS: Marijuana, hashish, hash oil

Yes □ No □

STIMULANTS: Cocaine, crack Yes □ No □

STIMULANTS: Methamphetamine (speed, ice, crank) Yes □ No □

HEROIN Yes □ No □

AMPHETAMINES/OTHER STIMULANTS: Ritalin, Benzedrine, Dexedrine Yes □ No □

BENZODIAZEPINES/TRANQUILIZERS: Valium, Librium, Halcion, Xanax, Diazepam Yes □ No □ SEDATIVES/HYPNOTICS/BARBITURATES: Amytal, Seconal, Dalmane, Quaaludes Yes □ No □

STREET OR ILLICIT METHADONE Yes □ No □

OPIOIDS: Norco, Vicodin, Lorcet, Lortab, Methadone Yes □ No □

HALLUCINOGENS: LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy Yes □ No □ INHALANTS: Glue, gasoline, aerosols, paint thinner, poppers, rush, locker room Yes □ No □

Hospitalizations Have you been recently hospitalized or participated in any outpatient programs? [ ] Yes (Complete Below) [ ] No When: Where: Reason:

Lab Work Please indicate which lab you prefer or that is in network with your insurance for blood work and/or Urinary Drug Analysis.

� � � Other:

Drug Allergies Please list any drug allergies and exactly how this medication affects you. (Examples: Rash, Hives, Itching, Swelling, etc.)

Medication Name: Type of Reaction:

Medication Name: Type of Reaction:

Pharmacy Information Please list your pharmacy information. Please present a copy of your prescription card to the front desk.

Local Pharmacy Name:

City: Pharmacy Number: Fax Number:

Mail Order Pharmacy:

City: State: Pharmacy Number: Fax Number:



Medication Consent Form

Please list ALL of the medications that you take below.

Medication Name, Strength and Directions

Anti-Depressant

Anti-Anxiety

Psycho-Stimulant

Mood Stabilizer

Neuroleptic

Sleep Aid

Anti-Craving

Other

1. ��

2. ��

3. ��

4. ��

5. ��

6. ��

7. ��

8. ��

9. ��

10. .�� Please stop here. The remainder of this form will be completed in your visit with the physician.

EDUCATIONAL METHODS USED – Check all that apply. � Verbal Explanation, specify if only method available. �

� Other Written Materials, specify. � � Side Effects; specify medication and associated side effect(s). �

WOMEN OF CHILD BEARING YEARS ONLY – Check all that apply. � I have been instructed in the safety of the above drugs in pregnancy. �

� I have been informed of any above drug interaction which would interfere with the effectiveness of my birth control pill in current / future use, and the necessity to use

alternate birth control measures. �

� If pregnant of breast feeding, I agree to discuss with my obstetrician or pediatrician before starting the medication(s).�

I have been instructed in the medication benefits, alternatives, side effects, and precautions of the above listed medications. My questions and concerns about the prescribed medication have been addressed and I agree to inform my provider if other questions and / or concerns should arise.

Patient/Guardian Printed Name Date/Time Patient/Guardian Signature Date

Nurse’s Printed Name Date/Time Nurse’s Signature Date

Provider’s Printed Name Date/Time Provider’s Signature Date



Agreement for Controlled Substances

It is our desire to provide you with excellent patient care and to help you achieve overall health and wellness. To help achieve that goal, your provider may prescribe a Controlled Substance medication (i.e., narcotics, sedatives benzodiazepines, stimulants and/or buprenorphine) which can be very useful, but have a significant potential for misuse and are, therefore; closely controlled by local, state, and federal authorities. In addition, the Texas Medical Board encourages urine drug screens in conjunction with a controlled substance contract to start or continue taking any controlled substance. Failure to sign and abide by this agreement will result in immediate termination of any controlled substances being prescribed by any provider in this office. Please carefully read through the entire agreement and initial by each item and fill your name in, indicating that you understand these requirements set forth by all PsyMed Practitioners. We look forward to working with you.

Sincerely, Oluyemi Aina, M.D., Staff, & Tri-MED Behavioral & Sleep Medicine

1. I am responsible for my medications. If the medications are lost, misplaced, or stolen, REGARDLESS OF THE REASON, I understand that my physician

WILL NOT be replacing or refilling my medication. I further understand that early refills WILL NOT be approved. (INITIAL)

2. I WILL NOT seek medications from any other physician or practitioner while I’m receiving the same medications from my provider of Tri-MED Behavioral & Sleep Medicine. We will regularly check the Texas Prescription Monitoring Program data base. The data base tells your provider of each prescription for controlled substances that you have filled from all practitioners and pharmacies. (INITIAL)

3. Suboxone Patients: I WILL NOT seek opiate medications from any other physician or practitioner while I’m receiving Suboxone therapy from my

Provider of Tri-MED Behavioral & Sleep Medicine. I further agree to inform my Provider of Tri-MED Behavioral & Sleep Medicine of any and all medical or dental procedures that will require the use of opiate medications. I agree to disclose to the surgical or medical physician that I am on Suboxone therapy and will sign a Release of Information fo the physicians to consult regarding medications and all surgical or medical procedures. ( INITIAL)

4. Concerning refills: I agree that refills of controlled substance medications will be made during regular office hours, in person, during a scheduled visit. It is your responsibility to take the medication as prescribed. Early refills will not be made, even if you have run out of your medication early. (INITIAL)

5. I WILL TAKE my medications as prescribed and as directed. I will not take extra medication without being advised to do so by my provider at Tri-MED Behavioral & Sleep Medicine. By doing so ensures that I will not run out of medications early. (INITIAL)

6. I WILL NOT use any illicit drugs, as defined by law. These include marijuana, heroin, methamphetamine, cocaine, PCP and hallucinogens or any other mood altering substance that is illegal. (INITIAL)

7. I understand that PsyMed Solutions will perform urine drug screening tests, at my expense, to verify compliance of my medication contract. If I am found to be using illegal substances for any reason, my Controlled substance medications will be discontinued immediately. NO EXCEPTIONS. In addition, if my urine drug screen is negative for medications prescribed by Tri-MED Behavioral & Sleep Medicine practitioners, my controlled substances medications will be discontinued immediately and will not be re-prescribed by any physician at Tri-MED Behavioral & Sleep Medicine . NO EXCEPTIONS. ( INITIAL)

8. I understand that if I violate any of the above conditions, my controlled substance prescriptions will be immediately terminated, and it will be reported to my other healthcare providers, medical facilities and pharmacies. (INITIAL)

9. I understand that my provider may discontinue my medication at any time if they no longer think it is clinically appropriate or in my best interest. Additionally, if my controlled substances are discontinued by my Tri-MED Behavioral & Sleep Medicine provider, this will apply to all other PsyMed Providers as well. No other practitioner in this practice will restart you on the medication. Lastly, once you have violated the agreements in this contract at no time will you ever be prescribed controlled substance by this practice again. (INITIAL)

I acknowledge the receipt of this agreement and that it has been explained to me in detail by a staff member at Tri-MED Behavioral & Sleep Medicine. I understand by signing below, I agree to comply with the terms and guidelines of this agreement.

Patient Printed Name Patient Signature

Clinician’s Printed Name Clinician’s Signature

Physician’s Printed Name Physician’s Signature Date:



Tri-MED Behavioral & Sleep Medicine Office Policies

Appointments: (Initial) x Our office hours are 8:00 am to 5:00 pm Monday through Friday. Patient appointments are scheduling by calling during regular office hours.

CANCELLATION/NO SHOW FEES: If your appointment is not canceled 24 hours in advance, our office will charge a rate of $50.00 per appointment that is NOT canceled and is payable prior to future visits. This fee will not be billed to the insurance company.�

x Confirmation calls are made via an automated system at least two days prior to a scheduled appointment. It is the patient’s responsibility to ensure Tri-MED Behavioral & Sleep Medicine has the most current contact information on file.�

x When a confirmation call is made and the patient does not answer the phone, a detailed voicemail will be left. If the voicemail is full or not setup, the patient will still be responsible if he/she does not come in for that appointment. Please remember that the confirmation call is a courtesy service provided by Tri-MED Behavioral & Sleep Medicine�

x PATIENT TARDY POLICY: If the patient is more than 15 minutes late to their appointment, they will need to reschedule. We will no longer be working patients into the schedule. If there happens to be an opening in the schedule later that day, the patient may be re-scheduled to that time slot; otherwise, they will be rescheduled.�

Financial Policy: (Initial) x An estimated payment is due at the time of service by cash, money order, Visa, MasterCard, Discover or American Express. WE DO NOT ACCEPT

PERSONAL CHECKS. Depending on the level of service provided, there may be an additional fee that is patient responsibility to pay within 30 days of receipt of your statement.�

x Patients are responsible for their co-payments and/or deductibles and coinsurance at the time services are rendered for patients on Preferred Provider Plans (PPO’s) or Health Maintenance Organizations (HMO’s).�

x Any balance on an account that is greater than 30 days old is considered past due.�x A statement will be mailed on a monthly basis and will reflect the current balance for all services rendered prior to the date on the statement. Payment is due

upon receipt of statement.�Insurance: (Initial)

x Your insurance policy is a contract between you and your insurance company. While our billing professionals will do all they can to help our patients in communicating and negotiating with their insurance plan or other persons, we must inform patients that if you have any questions regarding coverage, benefits, or payment for services provided, it is the patients responsibility to contact the insurance carrier and resolve.�

x In the event of denials, errors, or non-covered services, the patient is responsible for all services rendered. If payment from your insurance carrier is not received within forty-five (45) days, we will seek payment in full from you. Balance of services that are delayed or denied by your insurance company due to Coordination of Benefits information will become your responsibility after thirty (30) days.�

x I understand that if I have an HMO insurance plan, I might need a referral from my primary care physician through my insurance company with an authorization # before being seen. I understand that certain testing might need an authorization through my insurance company before being done, and I may not be able to get the test done the same day as my office visit until authorization is attained. I understand that I am responsible for all health insurance deductibles, copayments, and coinsurance charges not covered by my insurance policy. I understand that I will be responsible for charges not covered by my insurance policy that include, charges for services not medically necessary as determined by my insurance company. I understand and authorize in order for my claims to be processed that any policy holder of medical or other information about me be released to the social security and ministration and healthcare financing administration or its intermediaries, and any information needed for the claim. I permit a copy of this Authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits and other insurance companies apply. I understand that I am responsible for all cost not covered by my insurance.�

x Tri-MED Behavioral & Sleep Medicine and its employees do not guarantee that payment will be authorized for medical services; therefore, this office is not responsible for any adverse payment decisions or misuse of information.�

x Notification of any change in your insurance status (i.e. new company, deductible, co-pay amounts, and coinsurance) must be provided to the office forty-eight�(48) hours in advance of next visit or payment in full will be required.

Red Flag Policy: (Initial) x Tri-MED Behavioral & Sleep Medicine must collect and store our patient’s private medical, financial and personal identifying date. We must therefore be

vigilant in protecting the patient information to which we have access to including medical, financial, and any other personal information contained in Tri-MED Behavioral & Sleep Medicine appointment, or billing records.�

x You must present a valid state issued photo identification card prior to being seen at each appointment.�x If you would like us to bill your insurance carrier, you must present a valid insurance card prior to being seen at each appointment, or payment in full will be

required.�Medical Records: (Initial)

x Fees for medical records are $25.00 for the first 20 pages, and $0.50 for each page thereafter and may take up to 15 business days to obtain. Report preparation fees are based on the time involved.�

Refill Requests/Messages: (Initial) x All requests for prescription refills must be made during your office visit.�x Controlled Substance are not refilled without an appointment.�x Any phone messages left will be returned within 24 hours by the clinical staff and/or the physician if necessary.�

Emergency Situations/After Office Hours: (Initial) x We do not have an on-call or after hours emergency line. If you are having a medical emergency, please call 9-1-1 or go to the nearest emergency room,

Seay Behavioral Center ( Texas Health) or TMC Behavioral Center, Sherman, Texas to be evaluated.�



Cellular Devices, cameras, camcorders or any other recording/photo taking devices are PROHIBITED: (Initial) x To reduce the potential risk of a Federal HIPAA Violation, recording devices and/or photo taking devices are prohibited to include but are not limited to cell

phones, camcorders and records.�REVIEW ACKNOWLEDGEMENT OF NOTICE OF PRIVACY POLICES AND PRACTICES: (Initial)

x A COPY IS AVAILABLE IN PRINT UPON REQUEST�

I have read and understand the Office Policy and I agree to accept responsibility as described above. I also understand the Office Policy may be amended or modified from time to time by the practice. I am expressing my understanding by initialing next to each item on this page as well as signing below. If you have any questions, please feel free to ask our staff for assistance. Thank you for allowing us to assist in your care.

Patient Name (Please Print) Date

Signature of Patient or Guardian Relationship

CONSENT TO APPOINTMENT DELAYS

We are pleased that you have partnered with Tri-MED Behavioral & Sleep Medicine to assist you in addressing your health care needs. Occasionally, our healthcare providers are required to respond to urgent situations outside of the clinic. If your appointment time is significantly delayed, you may reschedule your visit or elect to be treated by one of our other providers. We respect that your time is valuable. Please remember that appointments in our clinic are in high demand. We request that you set aside enough time on the day of your scheduled appointment in anticipation of delays. Your patience is appreciated and we will do everything we can to accommodate your schedule.

By signing this document, the patient and/or patient’s guardian understands and agrees they have been advised that they may have an extended wait period for Dr. Aina and the Nurse practitioners. The patient and/or patient’s guardian also understands and agrees they have been given the option of scheduling with another provider in our clinic if the delay impedes on the patient’s schedule.



CONSENT TO TREATMENT

I hereby give Dr. ‘Yemi Aina and/or his associates’ permission to examine me and treat me according to the diagnosis and treatment plan as explained to me in order to improve my medical condition. I hereby authorize payment directly to Tri-MED Behavioral & Sleep medicine, Dr. Oluyemi Aina and/or his associates for medical services provided to me.



NOTICE OF NO COVERAGE FOR URINE DRUG SCREENS EFFECTIVE: FEBRUARY 3, 2017

Please be aware that your insurance company may not cover your urine drug screen, code G0477 or 80305. Please sign this form indicating that you understand it may not be covered and that you will be responsible for $12 if insurance denies payment. Thank you for your cooperation. By signing below, the patient and/or patient’s guardian acknowledges that he/she has read and understands the information regarding my benefits.



PATIENT NAME: DOB: DATE:

Please answer each question as accuratly as possible as to how you have felt and conductedyourself 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?

TOTALS:

ADULT ADHD SELF-REPORT SCALE

Scoring Questions: Any answer within box outline is a positive response.

Scoring categories: Category 1 is positive with 2 or more positive responses to questions 1-5Category 2 is positive with 2 or more positive responses to questions 6-8Category 3 is positive with 1 positive responses to questions 9-10

Final Result: If 2 or more possible categories are positive, you have a high likelihood of sleep apnea.

6. How often do you feel tired or fatigued after your sleep?

nearly every day3-4 times a week1-2 times a week1-2 times a monthnever or nearly never

7. During your waketime, do you feel tired, fatigued or not up to par?


while driving a vehicle?yesno

if yes, how often does it occur? nearly every day 3-4 times a week 1-2 times a week 1-2 times a month never or nearly never

9. Do you have high blood pressure?yesnodon’t know

10. BMI > 30 (See Chart)yesno

2 yrogetaC3 yrogetaC

1 yrogetaC

Please Complete the following:height ageweight male/female

1. Do you snore?yesnodon’t know

2. Your snoring is?slightly louder than breathingas loud as talkinglouder than talkingvery loud. Can be heard in adjacent rooms.

3. How often do you snore?nearly every day3-4 times a week1-2 times a week1-2 times a monthnever or nearly never

4. Has your snoring ever bothered other people?

yesno

5. Has anyone noticed that you quit breathing during your sleep?


Name

Address

Berlin QuestionnaireSleep Evaluation in Primary Care

If you snore:

EFFECTIVE IMMEDIATELY

Due to new FDA Regulation concerning Opioid and Benzodiazepine

combination, Tri-MED has made the following required protocol:

IF YOU ARE CURRENTLY TAKING BOTH AN OPIOID AND BENZODIAZEPINE MEDICATION, IT WILL BE AT THE

DISCRETION OF THE PHYSICAN AND/OR NURSE PRACTITIONER IF YOU REMAIN ON YOUR CURRENT DOSE OR IF YOU WILL BE

TITRATED OFF YOUR BENZODIAZEPINE MEDICATION.

This new protocol stems from the recent significant increase in overdose deaths due to the combination of these medications.

Patient Name:__________________________________________ DOB:___________________

Patient Signature:_______________________________________ Date:___________________

GAD-7 Anxiety

Column totals _____ + _____ + _____ + _____ =

Total score _______

Source: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at [email protected]. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permission

Scoring GAD-7 Anxiety Severity

This is calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of “not at all,” “several days,” “more than half the days,” and “nearly every day.” GAD-7 total score for the seven items ranges from 0 to 21. 0–4: minimal anxiety

5–9: mild anxiety

10–14: moderate anxiety

15–21: severe anxiety

Over the last two weeks, how often have you been bothered by the following problems?

Not at all

Several

days

More

than half the days

Nearly every day

1. Feeling nervous, anxious, or on edge

0

1

2

3

2. Not being able to stop or control worrying

0

1

2

3

3. Worrying too much about different things 0

1

2

3

4. Trouble relaxing

0

1

2

3

5. Being so restless that it is hard to sit still

0

1

2

3

6. Becoming easily annoyed or irritable

0

1

2

3

7. Feeling afraid, as if something awful might happen

0

1

2

3

If you checked any problems, how difficult have they 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

□ □ □ □

mailto:[email protected]

PATIENT NAME: DATE:

YES NO

1. Has there ever been a period of time when you were not your usual self and...

...you felt so good / hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

...you were so irritable that you shouted at people or started fights or arguments?

...you felt much more self-confident than usual?

...you got much less sleep than usual and found you didn’t really miss it?

...you were much more talkative or spoke much faster than usual?

...thoughts raced through your head or you couldn’t slow your mind down?

...you were so easily distracted by things around you that you had trouble concentrating or staying on track?

...you had much more energy than usual?

...you were much more active or did many more things than usual?

...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

...you were much more interested in sex than usual?

...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

...spending money got you or your family into trouble?

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

4. Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

5. Has a health professional ever told you that you have manic-depressive illness "" or bipolar disorder?

Please answer each question to the best of your ability.

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments/fights?

No Problem Minor Problem Moderate Problem Serious Problem

Please only circle ONE response below:

MOOD DISORDER QUESTIONNAIRE

PATIENT NAME: DATE

Over the last TWO WEEKS, how often have you been bothered by any of the following problems *use the scale provided to answer each question*

Not at all Several days

More than half the

days

Nearly every day

1. Little interest or pleasure in doing things0 1 2 3

2. Feeling down, depressed, or hopeless0 1 2 3

3. Trouble falling or staying asleep or sleeping too much0 1 2 3

4. Feeling tired or having little energy0 1 2 3

5. Poor appettite or overeating0 1 2 3

6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down0 1 2 3

7. Trouble concentratingon things, such as reading the newspaper or watching television0 1 2 3

8. Thought that you wouyld be better off dead, or of hurting yourself0 1 2 3

9. Moving or speaking so slow that other people could have noticed. Or the opposite- being so figety or restless that you have been moving around a lot more that usual

0 1 2 3

↓ ↓ ↓ ↓

ADD COLUMNS:

10. 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

Patient Health Questionnaire (PHQ9)

PTSD CheckList – Civilian Version (PCL-C) Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, pick the answer that indicates how much you have been bothered by that problem in the last month. Patient Name_________________________________________________________________ D.O.B. _____________

No. Response Not at all (1)

A little bit (2)

Moderately (3)

Quite a bit (4)

Extremely (5)

1. Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?

2.

Repeated, disturbing dreams of a stressful experience from the past?

3.

Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?

4.

Feeling very upset when something reminded you of a stressful experience from the past?

5.

Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?

6.

Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?

7.

Avoid activities or situations because they remind you of a stressful experience from the past?

8.

Trouble remembering important parts of a stressful experience from the past?

9. Loss of interest in things that you used to enjoy?

10. Feeling distant or cut off from other people?

11.

Feeling emotionally numb or being unable to have loving feelings for those close to you?

12. Feeling as if your future will somehow be cut short?

13. Trouble falling or staying asleep? 14. Feeling irritable or having angry

outbursts?

15. Having difficulty concentrating? 16. Being “super alert” or watchful on

guard?

17. Feeling jumpy or easily startled? PCL-M for DSM-IV (11/1/94) Weathers, Litz, Huska, & Keane National Center for PTSD-Behavioral Science Div.

How is the PCL Scored? 1) Add up all items from each of the 17 items for a total severity score (range = 17-85) 17-29 This cut off shows little to no severity. 28-29 Some PTSD symptoms - If you are seeing or will be seeing a therapist, print the results of this Quiz and take to your therapist for further evaluation. 30–44 Moderate to Moderately High severity of PTSD symptoms - If you are seeing or will be seeing a therapist, print the results of this Quiz and take to your therapist for further evaluation. 45-85 High Severity of PTSD symptoms - If you are seeing or will be seeing a therapist, print the results of this Quiz and take to your therapist for further evaluation.

Oluyemi Aina, M.D. · Oluyemi Aina, M.D. Joyce Mwaniki, MSN, PMHNP-BC 3140 Legacy Dr. Suite 710 •...

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