New Patient Assessment

New Patient Assessment
Check all that apply

Jabbok Treatment Center reserves the right to modify the privacy practices outlined in the Notice and I have received a copy of the Notice of Privacy Practices.In general, the HIPAA privacy rules, with HITECH updates, gives you the right to tell us how you want Protected Health Information(PHI) communicated to you and if there are other family members or close personal friends with whom you would want us to share this PHI.I authorize you to contact me by phone/text/email and mailing address given on this patient information sheet.I authorize you to share information with the person(s) listed below.I understand that Jabbok Treatment Center CURRENTLY does not accept insurance for comprehensive office visit. All visits are to be paid prior to being seen by the doctor.
Please initial that you have read each statement above.

PATIENT INFORMATION
Name

First NameLast Name
Gender
Age
Date of Birth
Marital Status
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
List any allergies(IF NONE, PLEASE WRITE NONE)
Insurance Name (Please include ID#, Group#, Payer ID#)
HIPPA- anyone with whom you allow us to share your protected health information? (IF NONE, PLEASE WRITE NONE)
Emergency Contact Name

First NameLast Name
Phone Number

Area CodePhone Number

Responsibility for Suboxone
I understand that Suboxone is currently being sold illegally in Tennessee.

I understand that Suboxone which is sold illegally often ends up in the prisons of Tennessee.

I understand that selling Suboxone is a crime.

To receive Suboxone, I understand that I have a responsibility for public safety.

I understand that random film/pill count are used by Jabbok Treatment Center to protect public safety.

I understand that I will not be prescribed Suboxone if:
- 1. I do not provide a requested film/pill count.
- 2. My film/pill count is significantly off.
- 3. I lose my Suboxone.
I understand that Suboxone is a narcotic. All narcotics, including Suboxone, have a set of benefits and set of risks to me. I will work to increase the benefits I receive from Suboxone. I acknowledge that the requirement of Federation of State Medical Boards is that I continue to improve in function in order to continue to receive my Suboxone.
Name

First NameLast Name

JABBOK TREATMENT CENTER PATIENT AGREEMENT
Patient Name

First NameLast Name
Check all that apply

I understand that this agreement between myself; and (Jabbok Treatment Center, LLC.) is intended to clarify the manner in which chronic (long-term) controlled substances will be used to manage my substance use disorder. Chronic controlled substance therapy for patients who do not suffer from cancer pain is a controversial issue.I understand that there are side effects to this therapy; these include, but are not limited to, allergic reactions, depression, sedation, decreased mental ability, itching, difficulty in urinating, nausea and vomiting, loss of energy, decreased balance and falling, constipation, decreased sexual desire and function, potential for overdose and death. Care should be taken when operating machinery or driving a car while taking these medications. When controlled substances are used long-term, some particular concerns include the development of physical dependence and addiction. I understand these risks and have had my questions answered by my physician.I understand that (Jabbok Treatment Center, LLC) physician will prescribe controlled substances only if the following rules are adhered to:
- All controlled substance prescriptions must be obtained from your(Jabbok Treatment Center) physician. If a new condition develops, such as trauma or surgery, then the physician caring for that problem may prescribe narcotics for the increase in pain that may be expected. I will notify my (Jabbok Treatment Center) physician within 48-hours of my receiving a narcotic or any ohter controlled substance from any other physician or other licensed medical provider. For females only: If I become pregnant while taking this medicine, I will immediately inform my obstetrician and obtain counseling on risks to the baby.
- I will submit urine and/or blood on request for testing at any time without prior notification to detect the use of non-prescribed drugs and medications and confirm the use of prescribed ones. I will submit to pill counts without notice as per physician's request. I will pay any portion of the costs associated with urine and blood testing that is not covered by my insurance.
- All requests for refills must be made by contacting my (Jabbok Treatment Center) physician during business hours at least 3-workdays in advance of the anticipated need for the refill. All prescriptions must be filled at the same pharmacy, which is authorized to release a record of my medications to this office upon request. A copy of this agreement will be sent to my pharmacy.
Pharmacy name/address/telephone:
- The daily dose may not be changed without my (Jabbok Treatment Center) physician's consent. This includes either increasing or decreasing the daily dose.
- Prescription refills will not be given prior to the planned refill date determined by the dose and quantity prescribed. I will accept generic medications.
- Accidental destruction, stolen and loss of medications or prescriptions will not be a reason to refill medications or rewrite prescriptions early. I will safeguard my controlled substance medications from use by family members, children or other unauthorized persons.
- You may be referred to an appropriate specialist to evaluate your physical condition.
- You may be asked to have an evaluation by either a psychiatrist or psychologist to help manage your medication needs.
- If your physician determines that you are not a good candidate to continue with the medication, you may be referred to a detoxification program or evaluation by a pain management center.
- These medications may be discontinued or adjusted at your physician's discretion.
- I understand that it is my physician's policy that all appointments must be kept or cancelled at least 2-working days in advance.
- I undestand that I am responsible for meeting the terms of this agreement and that failure to do so will/may result in my discharge as a patient of (Jabbok Treatment Center). Grounds for dismissal from (Jabbok Treatment Center) include, but are not limited to: Evidence of recreational drug use, of drug diversion, of altering scripts (this may result in criminal prosecution), of obtaining controlled substance prescriptions from other doctors without notifying this office, abusive language toward staff, development of progressive tolerance, use of alcohol or intoxicants, engagement in criminal activities, etc.
Please initial that you have read the statements above.

PRESCRIPTION PAIN KILLERS:

What did you use, how many per day, and how many to get high?

Drug

	# to get high	Not used currently	Never used
Morphine
Oxycodone/OxyContin,Roxicodone
Fentanyl/Fentanyal Patch
Oxymorphine/Opana
Hydrocodone

METHADONE MAINTENANCE TREATMENT:
Have you been in Methadone Maintenance Treatment?

Program Name

	Location	Time in treatment	Stop Date	Dosage	Days/Month to Relapse
BHG
Solutions of Savannah

How well did methadone work for you?
Did you have any of the following side effects from methadone? Check all that apply

ConstipationMild drowsinessExcess sweatingPeripheral edemaReduced libido
Why did you discontinue methadone maintenance?
What was your withdrawal like?
Any comments about methadone?
BUPRENORPHINE (SUBOXONE):
Illicit Use/Street Purchase of Buprenorphine:

YESNO
How much have you been using?
How long have you been using street buprenorphine?
Have you been in a Buprenorphine Detox/Maintenance Program before?

YESNO

List prior programs:

	Physician	Location	Detox	Maintenance	Duration	End date	Relapse
1.
2.
3.
4.
5.

Comments on buprenorphine treatments:

	Mark current living situation
Married with children
Domestic Partner with children
Single with children
Married no children
Domestic Partner no children
Single no children living alone
Live with Parents
Live with Roommates

	Total dollar per month
Employment (take home pay)
Unemployment Compensation
Welfare
Pension Benefit

Should be Empty:

	Life time use in years	When stopped: Date or Years
Alcohol
Benzodiazepines
Alprazolam
Amphetamines
Methamphetamines
Cannabis
Hallucinogens
Inhalants
Opiates
Cocaine

	Opioids	Alcohol	Tobacco	Marijuana	Cocaine	Methamphetamines
FATHER
MOTHER
BROTHERS/SISTERS
AUNTS/UNCLES
GRANDPARENTS
CHILDREN
SIGNIFICANT OTHER

	Major Depression	Bipolar	Anxiety	Schizophrenia	Suicide	Psychiatric Hospitalizations
FATHER
MOTHER
BROTHERS/SISTERS
AUNTS/UNCLES
GRANDPARENTS
CHILDREN
SIGNIFICANT OTHER

	Jail	Prison	How long in jail/prison?
FATHER
MOTHER
BROTHERS/SISTERS
AUNTS/UNCLES
GRANDPARENTS
CHILDREN
SIGNIFICANT OTHER

New Patient Assessment

PATIENT INFORMATION

Responsibility for Suboxone

JABBOK TREATMENT CENTER PATIENT AGREEMENT

COMPREHENSIVE HISTORY