Patient Form

Perfect Balance Psychiatric Services and TMS Center

Step 1

patient information

Last Name

First Name

Middle Initial

Preffered Name

Date of Birth

Mailing Address(Street)

City

State

Zip Code

Phone Number (Cell)

Phone Number(Home)

Social Security

Emergency Contact

Relationship

Insurance information/ Responsible Party Information

Primary Insurance

Insurance Subscriber

Subscriber's DOB

Relation to Patient

Policy #/Member ID

Group ID #

Secondary Insurance

Policy #/Member ID

Group ID #

HEALTHCARE PROVIDERS

Primary Care Provider

Phone

Fax

Therapist

Phone

Fax

Psychiartrist

Phone

Fax

I authorize release of the results of my treatment upon conclusion to:

PRIMARY CARE PHYSICIAN

PSYCHIATRIST

THERAPIST

Patient Signature

(Guardian’s Signature if Patient is under 18)

Today's Date

Step 3

7.In the past few years have you used any of the following substances:

Substances Used	Age first started	Use frequency	Years Used	Last use	Current use	Treatment
Cannabis/ Mj/ Weed
COCAINE
AMPHETAMINES/METH Other Stimulants
HEROIN or OTHER OPIOIDS- Pain pills
HALLUCINOGENS LSD, PCP, Mushrooms Ecstasy, Nitrous Oxide
Inhalants

Primary Care Physician (please print their name)

Current Medical Issues

Do you have any of the following medical problems?

Past Surgical History

Menstrual History

Pregnancies

ALL PATIENTS/RESPONSIBLE PARTIES PLEASE READ AND SIGN BELOW

By signing below, I attest I have answered all questions truthfully and t the best of my knowledge

Patient Signature

(Guardian’s Signature if Patient is under 18)

Today's Date

Step 4

Patient Name

ADVICE

Final diagnosis should be made with clinical interview and mental status examination including assessment of patient’s level of distress and functional impairment.

MANAGEMENT

PHQ-9 Management Summary

Score	Depression severity	Comments
0-4	Minimal or none	Monitor; may not require treatment
5-9	Mild	Use clinical judgment (symptom duration, functional impairment) to determine necessity of treatment
10-14	Moderate
15-19	Moderately severe	Warrants active treatment with psychotherapy, medications, or combination
20-27	Severe

CRITICAL ACTIONS

Perform suicide risk assessment in patients who respond positively to item 9 “Thoughts that you would be better off dead or of hurting yourself in some way.”
Rule out bipolar disorder, normal bereavement, and medical disorders causing depression.

FORMULA

Addition of the selected points.

FACTS & FIGURES

The PHQ-9 is a validated, 9-question tool to assess for the degree of depression present in an individual; the last question is not scored, but is useful functionally to help the clinician assess the impact of the patient's symptoms on his or her life.

EVIDENCE APPRAISAL

The PHQ-9 was initially developed by Kroenke et al (2001), as a subset of 9 questions from the full PHQ, which had previously been derived and studied in a cohort of 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics (Spitzer 1999). PHQ-9 scores ≥10 were found to be 88% sensitive and also 88% specific for detecting MDD. Criterion validity was also assessed in a sample of 580 patients.

The PHQ-9 has also been validated in several additional subpopulations, including in psychiatric patients (Beard 2016), patients with medical comorbidities such as multiple sclerosis (Ferrando 2007) and Parkinson’s disease (Chagas 2013), pregnant patients (Sidebottom 2012), and in an occupational health setting (Volker 2016).

A meta-analysis of 29 studies including 6,725 patients found similar sensitivity (88%, 95% CI 83-92%) and specificity (85%, 95% CI 82-88%) for a cutoff of ≥10 as did the previous studies, both overall and for subgroups. Notably, they found that when used in the primary care setting, only approximately 50% of patients screening positive on the PHQ-9 in fact had major depression (Levis 2019).

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective Date of Notice: January 01, 22

This Notice of Privacy Practices applies to the following organizations.

Perfect Balance Psychiatric Services

I am a patient of Perfect Balance Psychiatric Services. I hereby acknowledge receipt of Perfect Balance Psychiatric Services’ Notice of Privacy Practices.

Patient Signature

(Guardian’s Signature if Patient is under 18)

Today's Date

Perfect Balance Psychiatric Services and TMS Center

Step 1

patient information

Insurance information/ Responsible Party Information

HEALTHCARE PROVIDERS

Step 2

HEALTH HISTORY QUESTIONAIRE

3. Do you have any of the following implants in your body?

Step 3

7.In the past few years have you used any of the following substances:

Step 4

0

We offer options for payments:

Changes to the Terms of This Notice

This Notice of Privacy Practices applies to the following organizations.