New Patients - Hill Recovery

1. PATIENT INFORMATION
First Name
Last Name
How Were You Referred To Us?
Home #
Cell #
Email
Street Address
Address Line 2
City
State
ZIP Code
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
SSN
VEHICLE INFORMATION (REQUIRED IF DRIVING TO TREATMENT)
Make
Year
Model
Color
Licence Plt. #
DL #
Marital Status
Spouse Name
Spouse Cell
Primary Care Physician/First & Last Name
Adresss
Phone #
2. EMPLOYER INFORMATION IF INSURED
Employer Name
Phone
Street Address
City
State / Province / Region
ZIP / Postal Code
3. INSURANCE INFORMATION
Insurance Company
Policy #
Insured's Last Name
First Name
Relationship to the Patient
Birth Date
SSN
Insured Address
City
Zip
I give my permission for the staff of Hill Alcohol and Drug to contact the following person, as staff deems necessary.*

I do
1st Contact Name
Relationship
Home #
Cell #
Work #
Date
Patient/Responsible Party Signature
TO BE COMPLETED BY PATIENT And/Or MINOR'S FAMILY
Patient ID
Referral Source
Assessment Date
Name
Nickname
D.O.B.
Age
Marital Status
Number of Children
Ages
Who do you live with?
What language is spoken at home?
Where do you consider home? (Country, State, Region)
How would you describe your cultural background?
What groups or organizations do you belong to?
What do we need to understand about your beliefs, culture, or traditions to better help you in treatment?
Are you afraid to talk about yourself in a group?

Huge fearSignificant fearSome anxietyNot fearful at all
How can we help you deal with your anxiety?
What, specifically, has happened that brings you here today?
1. LEGAL
HAVE YOU EVER BEEN ARRESTED FOR ANY OF THE FOLLOWING?
Drinking & Driving?

YesNo
BAC?
How many DUI's?
When?
Domestic Violence?

YesNo
Year
Alcohol or Drug Intoxication?

YesNo
Year
Possession of Drugs or Paraphernalia?

YesNo
Year
Sale of Drugs?

YesNo
Year
Prescription Forgery?

YesNo
Year
Doctor Shopping?

YesNo
Year
Any Offense?

YesNo
Year
Are you on Probation or Parole?

YesNo
Officer's Name:
*REMINDER: RELEASE TO BE SIGNED BY OFFICER.
Do you have an immediate family member that is currently incarcerated or is having legal issues?

YesNo
2. EMPLOYER
How do you financially support yourself?
Job Title?
Length of Job?
If working, what is your work schedule?
Who helps you financially?
Does your employer suspect that you have a problem with substances?

YesNo
Did your employer mandate treatment?

YesNo
If yes, please explain:
Does your employer need reports from us?

YesNo
*REMINDER: RELEASE TO BE SIGNED BY OFFICER.
Absenteeism?

YesNo
Tardiness?

YesNo
Intoxication?

YesNo
Theft?

YesNo
Positive Urinalysis?

YesNo
Other?

YesNo
If other, please describe?
If unemployed, reason for unemployment:
Is your employer supportive of treatment?

YesNo
3. HEALTH
Has a Health Care Professional ever:?

a. Expressed concerns over your Alcohol or Drug use?b. Recommended that you reduce or discontinue use?c. Recommended Treatment or Detox?
If yes, please describe:
4. FAMILY
Has a Family Member ever:

a. Expressed concerns over your Alcohol or Drug use?b. Made excuses for your behavior?c. Had to drive you because of intoxication?d. Been to AI-Anon or therapy to improve coping with a loved one's drug use?
WHO WILL ATTEND FAMILY PROGRAM?
Name:
Relationship:
Phone:
Does anyone in your home abuse substances?

YesNo
Who?
What substance?
5. GENERAL
Do most of your friends drink or use drugs?

YesNo
Have you ever attended AA or NA meetings?

YesNo
Have you ever attempted to stop or cut down use?

YesNo
Has Substance Use interfered with enjoyment of leisure activities?

YesNo
Do you think about or plan for getting high frequently?

YesNo
Do you utilize community resources (support groups,social services, school-based services)?

YesNo
Last grade completed in school?
Degree, certifications, orlicenses you hold?
Specialized training that you have had?
Military History:
6. SPIRITUAL ASSESSMENT
Is religion or spirituality important in your life?

YesNo
What do you feel is your purpose in life?
Do you affiliate with a particular church or religion now?

YesNo
Were you raised in a particular belief or religion?

YesNo
If yes, which?
What is your perception of a "Higher Power" or "Power greater than yourself"?
Is Prayer or Meditation something you are comfortable with?

YesNo
7. DISCHARGE PLANNING
How motivated are you to achieve sobriety?
Where do you plan on living following treatment?
Other:
Patient Signature
Date
Patient/Guardian Signature
Date
Hill Alcohol and Drug Treatment Health questionnaire
Name:
Date:
SECTION 1 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
1. Do you currently have any contagious health problems or illnesses (such as tuberculosis or active pneumonia).
a. When did the condition start?
b. Who is the treating health care provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?ke for this condition?
e. How is the medication and/or other intervnetions working?
2. Are you running a fever today?
a. When did the condition start?
b. Who is the treating health care provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?ke for this condition?
e. How is the medication and/or other intervnetions working?
3. Do you have a rash or skin lesions with drainage now?
a. When did the condition start?
b. Who is the treating health care provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?ke for this condition?
e. How is the medication and/or other intervnetions working?
SECTION 2 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
4. Have you ever had a stroke?
a. When did the condition occur?
b. Who is the treating health care provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other intervnetions working?
5. Have you ever had a head injury that resulted in a period of loss of consciousness?
a. When did the condition occur?
b. How long were you unconscious?
c. Do you still have problems such as dizziness or loss of memory?
d. Who is the treating health care provider?
e. What medication do you take for this condition?
f. What else are you doing to help this condition?
g. How is the medication and/or other interventions working?
6. Have you experienced or suffered any chest pains recently?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
7. Have you ever been diagnosed with MRSA?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
SECTION 3 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
8. Have you ever had a heart attack or any problem associated with the heart?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
9. Have you ever had blood clots in the legs or elsewhere that required medical attention?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
10. Have you ever had high-blood pressure or hypertension?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
11. Do you have a history of cancer?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
SECTION 4 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
12. Do you have a history of any other illness that may requite frequent medical attention?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
13. Do you have allergies to medications, foods, animals, chemicals, or any other substance?
a. What are you allergic to?
b. What is your specific allergic reaction?
c. Who is the treating healthcare provider?
d. What medication do you take for this condition?
e. What else are you doing to help this condition?
f. How is the medication and/or other interventions working?
14. Have you ever had an ulcer, gallstones, internal bleeding, or any type of bowel or colon inflammation?
a.What is the specific condition?
b. When did the condition occur?
c. Who is the treating healthcare provider?
d. What medication do you take for this condition?
e. What else are you doing to help this condition?
f. How is the medication and/or other interventions working?
15. Have you ever been diagnosed with diabetes?
a. When was the condition diagnosed?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
SECTION 5 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
16. Have you ever been diagnosed with any type of hepatitis or other liver illness?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
17. Have you ever been told you had problems with your thyroid gland, been treated for, or told you need to be treated for any type of glandular disease?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
18. Do you currently have any lung diseases such as asthma, emphysema, or chronic bronchitis?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
19. Do you use nicotine?
a. How many packs per day?
For how many years?
b. Do you desire to quit?
c. Have you quit before
d. How long did you quit for?
e. What method did you use to quit?
SECTION 6 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
20. Have you ever had kidney stones or kidney infections, or had problems, or been told you have problems with kidneys or bladder?
a. When did the condition start?
b. Who is the treating healthcare provider?
c. What medication do you take for this condition?
d. What else are you doing to help this condition?
e. How is the medication and/or other interventions working?
Arthritis
When did this start?
Back Problems
When did this start?
Bone Injuries
When did this start?
Muscle Injuries
When did this start?
Joint Injuries
When did this start?
a. Who is the treating healthcare provider?
b. What medication do you take for this condition?
c. What else are you doing to help this condition?
d. How is the medication and/or other interventions working?
e. Additional Info:
22. Have you had any surgeries or hospitalizations due to illness or injury?
Date of incident:
Please describe:
Date of incident:
Please describe:
Date of incident:
Please describe:
Date of incident:
Please describe:
SECTION 7 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.
23. When was the last time you saw a physician including a psychiatrist?
What was the purpose of this visit?
24. Do you take any prescription psychiatric medications?
Type:
Dosage:
Frequency:
Is it helping?
Type:
Dosage:
Frequency:
Is it helping?
25. Do you wear or need to wear glasses, contact lenses, or hearing aids?
Details:
26. Do you have difficulty hearing?
Details:
27. Do you have difficulty reading?
Details:
28. What is the date of your last dental exam?
29. Are you in need of dental care?
Details:
What has prevented you from getting care?
30. Do you wear or need to wear dentures or other dental appliances?
Details
31. Are you pregnant?
SECTION 8 DETOX RISK ASSESSMENT
32. State of General Health?
33. Have withdrawal symptoms occurred when you have become abstinent in the past?
Details:
How many withdrawal episodes have you experienced?
34. Have you ever had a seizure or DT's?
Date:
Cause of seizure?
Last date that substance was used?
Alcohol:
Tranquilizers:
Painkillers:
Sleeping Medications:
36. Are you currently experiencing any of the following?
1. Extreme Anxiety
2. Tremors
3. Diaphoresis (sweating)
4. Nausea/Vomitting
5. Diarrhea
6. Muscle Cramps
7. Visual Distortions
8. Auditory Hallucinations
9. Tactile Hallucinations
10. Insomnia
11. Loss of appetite
12. Cravings
1. Have you ever used IV drugs?
2. If you are currently using IV drugs...is the injection area infected or abscessed?
3. Have you ever participated in unsafe or unprotected sex?
4. Have you had a blood transfusion?
5. Have you been sexually active with an IV drug user?
6. Have you been tested for HIV?
When:
Results:
Referral for HIV Test to:
7. Do you identify self as part of LBGT Community?
SECTION 8 FAMILY MEDICAL HISTORY
37. Has a 1st degree relative had the following:
Addiction
Asthma
Cancer
Diabetes
Stroke
Rheumatoid Arthritis
Depression
Bi-Polar Disorder
Heart Disease
Lupus
Blood Clots
If yes to any of the above, please complete the following:
Condition 1
Family Member
Type of Medication Prescribed/Used
Response to Medication
Condition 2
Family Member
Type of Medication Prescribed/Used
Response to Medication
Condition 3
Family Member
Type of Medication Prescribed/Used
Response to Medication
Condition 4
Family Member
Type of Medication Prescribed/Used
Response to Medication
Condition 5
Family Member
Type of Medication Prescribed/Used
Response to Medication
Signatures & Dates
Patient Signature
Date
Program Nurse Signature
Date
EARLY TERMINATION AGREEMENT
I, (Your Name)*
acknowledge that the assessme·nt and/or doctor visit fees(where applicable) are included when I start the Hill Alcohol and Drug Treatment program. Should I decide not to come into the program, I understand that I will be charged to cover the costs of the services rendered at the rates shown below.

Dr. Visit
Price: $200.00

Assessment/Intake Fee
Price: $300.00
Patient
Date
Responsible Party
Date
Witness
Date
Should be Empty:

1. PATIENT INFORMATION

MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

VEHICLE INFORMATION (REQUIRED IF DRIVING TO TREATMENT)

2. EMPLOYER INFORMATION IF INSURED

3. INSURANCE INFORMATION

TO BE COMPLETED BY PATIENT And/Or MINOR'S FAMILY

1. LEGAL

HAVE YOU EVER BEEN ARRESTED FOR ANY OF THE FOLLOWING?

*REMINDER: RELEASE TO BE SIGNED BY OFFICER.

2. EMPLOYER

*REMINDER: RELEASE TO BE SIGNED BY OFFICER.

3. HEALTH

4. FAMILY

WHO WILL ATTEND FAMILY PROGRAM?

5. GENERAL

6. SPIRITUAL ASSESSMENT

7. DISCHARGE PLANNING

Hill Alcohol and Drug Treatment Health questionnaire

SECTION 1 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 2 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 3 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 4 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 5 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 6 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 7 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

SECTION 8 DETOX RISK ASSESSMENT

SECTION 8 FAMILY MEDICAL HISTORY

EARLY TERMINATION AGREEMENT