Clone of New Patient Registration Form

1
How did you first hear about ASI?* This field is required.
Google Search
Google Maps
Attorney/Law Firm
Probation/Parole
Court/Court Staff
Treatment or Healthcare Provider
Family/Friend
Former ASI Client
Previous ASI Client
Social Media
Online Advertisement
Community/Professional Organization
Other
2
Patient Name* This field is required.
First Name
Middle Name
Last Name
3
Street Address* This field is required.
Address Line 1
4
City* This field is required.
5
State* This field is required.
Please Select
Please Select
AL : Alabama
AK : Alaska
AZ : Arizona
AR : Arkansas
CA : California
CO : Colorado
CT : Connecticut
DC : District of Columbia
DE : Delaware
FL : Florida
GA : Georgia
HI : Hawaii
ID : Idaho
IL : Illinois
IN : Indiana
IA : Iowa
KS : Kansas
KY : Kentucky
LA : Louisiana
ME : Maine
MD : Maryland
MA : Massachusetts
MI : Michigan
MN : Minnesota
MS : Mississippi
MO : Missouri
MT : Montana
NE : Nebraska
NV : Nevada
NH : New Hampshire
NJ : New Jersey
NM : New Mexico
NY : New York
NC : North Carolina
ND : North Dakota
OH : Ohio
OK : Oklahoma
OR : Oregon
PA : Pennsylvania
RI : Rhode Island
SC : South Carolina
SD : South Dakota
TN : Tennessee
TX : Texas
UT : Utah
VT : Vermont
VA : Virginia
WA : Washington
WV : West Virginia
WI : Wisconsin
WY : Wyoming
6
Zip Code* This field is required.
7
County of Residence * This field is required.
8
Date of Birth* This field is required.
Month
Day
Year
9
Social Security Number* This field is required.
10
Contact Number* This field is required.
Area Code
Phone Number
11
E-mail* This field is required.
12
Name of Insurance Company* This field is required.
Please Select
Please Select
Blue Cross Blue Shield
United Health Care/UHC/Optum
Cigna
Aetna
Iowa Medicaid- Amerigroup
Iowa Medicaid- Total Care
Other
None
13
Drivers License (Front)* This field is required.Or Other Form of Photo ID or Picture of Self
14
Drivers License (Back)* This field is required.Or Other Form of Photo ID
15
Sex* This field is required.
Male
Female
Refused
16
Military Status* This field is required.
Please Select
Veteran
Non Veteran
17
Marital Status* This field is required.
Please Select
Divorced
Never Married
Now Married
Separated
Widowed
Refused
18
Primary Source of Income* This field is required.
Please Select
Wages/Salary
Disability
Public Assistance
Retirement/Pension
None
Other
Refused
19
Sexual Orientation* This field is required.
Straight/Heterosexual
Gay/Lesbian
Bisexual
Other
Refused
20
Ethnicity* This field is required.
Puerto Rican
Mexican
Cuban
Other Hispanic or Latino
Not of Hispanic or Latino origin
Hispanic or Latino-Specific Origin no specified
Refused
21
Race* This field is required.
White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Another Race
Refused
22
Referral Source* This field is required.
Refused
Individual/Self
Alcohol/Drug Use Care Provider
Other Health Care Provider
School (Educational)
Employer/Employee Assistance Program (EAP)
Other Community Referral
State/Federal Court
Other Court
Probation/Parole
Other Recognized Legal Entity
Diversionary Program
Prison
OWI/DUI
Other Criminal Justice Referral
Unknown Criminal Justice
23
Who referred you to our office?* This field is required.Please use n/a if not applicable
24
Who referred you to our office?* This field is required.
Please Select
Attorney/Law Firm
Probation Officer
Parole Officer
Judge/Court
Clerk of Court/Court Staff
County Attorney/Prosecutor
Law Enforcement
DOT/Drivers License Reinstatement
Treatment Provider/Substance Use Provider
Mental Health Provider/Therapist
Medical Provider/Doctors Office
Employer/EAP
School/College/University
Family Member or Friend
Former ASI Client/Participant
Other
25
Please provide the name of the person or organization that referred you, if known: * This field is required.
26
Email of referral source for reporting purposesif known, see above
example@example.com
27
Phone number of referral source for reporting purposesif known, see above
Area Code
Phone Number
28
Arrests in the past 30 days* This field is required.
Yes
No
Refused
Type option 4
29
Arrests Related to Substance Use in Past 30 DaysRequired if above is yes (e.g. OWI/Possession/Public Intoxication, etc.)
YES
NO
Refused
30
Arrests in the past 12 months* This field is required.
Yes
No
Refused
31
If yes, how many times?required if above response is yes
32
How many arrests PRIOR TO THE LAST 12 MONTHS* This field is required.
0
1
2
3
4 or more
Refused
33
Occupation * This field is required.
34
Do you feel safe at home?* This field is required.
No
Yes
Please ask me more about this
35
Are you currently pregnant?* This field is required.
YESNO
36
Health Insurance* This field is required.
Private Insurance
Blue Cross/Blue Shield
Medicare
Medicaid (Amerigroup/Total Care)
HMO
Other
None
Refused
37
Living Arrangement* This field is required.
Please Select
Dependent living
Dependent living - Crisis residence
Dependent living – Foster home/Foster care
Dependent living - Institutional setting
Dependent living - Jail/Correctional facility/Other institutions under the justice system
Dependent living - Private residence
Dependent living - Residential care
Homeless
Independent living
Private residence, living arrangement not specified
Unknown
38
Education Grade Level* This field is required.
Please Select
1st year of college/university (freshman)
2nd year of college/university (sophomore) or associate's degree
3rd year of college/university (junior)
4th year of college/university (senior) or bachelor's degree
Grade 1
Grade 10
Grade 11
Grade 12 or GED
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Kindergarten
Less than one school grade or no schooling
Master's Degree Completed
Nursery school, preschool (includes Head Start)
Post-Graduate Study - 19 Years completed
Post-Graduate Study - 20 Years completed
Post-Graduate Study - 21 Years completed
Post-Graduate Study - 22 Years completed
Post-Graduate Study - 23 Years completed
Post-Graduate Study - 24 Years completed
Post-Graduate Study - 25 Years completed
Refused
Self-contained special education class
Some post-graduate study
Vocational school
39
Employment Status* This field is required.
Refused
Full Time
Part Time
Unemployed
Not In Labor Force- Homemaker
Not In Labor Force- Student
Not In Labor Force- Retired
Not In Labor Force- Disabled
Homeless
Not In Labor Force- Other
40
Education Grade Level (Highest Completed)* This field is required.
Refused
Less than one grade or no schooling
10-11
12 or GED
Vocational School
Self-contained special education
1st year college
2nd year college
3rd year college
4th year college
Some post-graduate study
Masters Degree Completed
Post-graduate study 19-25 years
41
What are we seeing you for?* This field is required.Please let us know why you are needing services?
OWI Evaluation
Non OWI Evaluation
On my own behalf seeking help
Other
Refused
42
If being seen for an OWI, have you completed the DOT mandated Drinking Drivers Education Class (OWI Weekend Program) ?* This field is required.
Yes
No
NA
43
How would you rate your quality of life?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very Satisfied
44
How satisfied are you with your health?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
45
How satisfied are you with your ability to perform your daily living activities?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
46
How satisfied are you with yourself?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
47
How satisfied are you with your personal relationships?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
48
How satisfied are you with the conditions of your living place?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
49
How satisfied are you with your mental health?* This field is required.
Very Dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
50
Do you have enough energy for everyday life?* This field is required.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
51
Do you have enough money to meet your needs?* This field is required.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
52
Have you attended AA/NA in the past 30 days?* This field is required.
YESNO
53
If yes, number of days attended in the last 30
54
Are you in care for a mental health disorder?* This field is required.
Yes
No
Refused
55
How many times have you been treated for substance use?* This field is required.
56
Please select all substances used* This field is required.
Alcohol
Aerosols
Alprazolam (Xanax)
Amobarbital, pentobarbital (Nembutal), and other barbituates
Amphetamine
Anestethics (chloroform, ether, nitroux oxide)
Bath salts, phenmetrazine, and other amines
Buprenorphine (Subutex, Suoxone)
Butorphanol (Stadol), morphine (MS Contin), opium and other narcotics
Choral hyrdrate and other non-barbituates sedatives/hypnotics
Chlordiazepoxide (Librium)
Cigarettes
Cigars or Pipes
Clonazepam (Klonopin, Rivotril)
Clorazepates (Tranxene)
Codeine
Combo/more than 1
Cocaine/Crack
Diazepam (Valium)
Diphenhydramine
Diphenylhydantoin/Phenytoin (Dilantin)
DMT, mescaline, peyote, psilocybin, STP and other hallucinogens
E-Cigarette/Vaping
Ethchlorvynol (Placidyl)
Flunitrazepam (Rohypnol)
Flurazepam (Dalmane)
Gasoline, glue, and other inappropriately inhaled products
Glutethimide (Doriden)
Halazepam, oxazepam (Serax), prazepam, temazepam (Restoril)
Heroin
Hydrocodone (Vicodin)
Hydromorphone (Dilaudid)
Ketamine (Special K)
Kratom
Lorazepam (Ativan)
LSD
Marijuana/Hashish, THC, and any other cannabis sativa preparation
MDMA, Ecstasy
Meperidine (Demerol)
Meprobamate (Miltown)
Methamphetamine/speed
Methaqualone (Quaalude)
Methylphenidate (Ritalin)
Nitrites
Non-prescription methadone
Other antihistamines, aspirin, Dextromethorphan (DXM) or other over the counter medications
Oxycodone (Oxycontin)
PCP
Pentazocine (Talwin)
Phenobarbital
Propoxyphene (Darvon)
Secobarbital/Amobarbital (Tuinal)
Smokeless Tobacco
Solvents (paint thinner and other solvents)
Synthetic Cannabinoid (Spice), Carisoprodol (Soma)
Tramadol (Ultram)
Triazolam (Halcion)
Unknown
None
57
What was the route of administration for the aforementioned substance(s)?* This field is required.
Inhalation
Injection
Oral
Other
Refused
58
Substance use in the past 30 days?* This field is required.
Please Select
1-2 days in the past week
1-3 days in the past month
3-6 days in the past week
Daily
None in the past month
59
What was the first age of use?* This field is required.
60
How many days within the last 12 months have you engaged in binge drinking?* This field is required.Current guidance on binge drinking is identified as 5+ drinks per occasion for males and 4+ drinks per occasion for females
61
1. How often do you have a drink containing alcohol?* This field is required.
Never (0)
Monthly or less (1)
2-4 times a Month (2)
2-3 times a week (3)
4 or more times a week (4)
62
2. How many drinks containing alcohol do you have on a typical day when you are drinking?* This field is required.
0-2 (0)
3 or 4 (1)
5 or 6 (2)
7-9 (3)
10 or more (4)
63
3. How often do you have six or more drinks on one occasion?* This field is required.
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)
64
4. How often during the last year have you found that you were not able to stop drinking once you had started?* This field is required.
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)
65
5. How often during the last year have you failed to do what was normally expected of you because of drinking?* This field is required.
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)
66
6. How often during the last year have you needed a first drink in the morning to to get yourself going after a heavy drinking session?* This field is required.
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)
67
7. How often during the last year have you had a feeling of guilt or remorse after drinking?* This field is required.
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)
68
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?* This field is required.
Never (0)
Less than monthly (1)
Monthly (2)
Weekly (3)
Daily or almost daily (4)
69
9. Have you or someone else been injured because of your drinking?* This field is required.
No (0)
Yes but not in the last year (2)
Yes, in the last year (4)
70
10. Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested you cut down?* This field is required.
No (0)
Yes but not in the last year (2)
Yes, in the last year (4)
71
Have you ever been in treatment for an alcohol problem?* This field is required.
Never
Currently
In the past
72
1. Have you used drugs other than those required for medical reasons?* This field is required.
YESNO
73
2. Do you abuse more than one drug at a time?* This field is required.
YESNO
74
3. Are you always able to stop using drugs when you want to? (If never used, answer "yes"). * This field is required.
YESNO
75
4. Have you had "blackouts" or "flashbacks" as a result of drug use?* This field is required.
YESNO
76
5. Do you ever feel bad or guilty about your drug use? (If never use drugs, choose "no"). * This field is required.
YESNO
77
6. Does your spouse (or parents) ever complain about your involvement with drugs?* This field is required.
YESNO
78
7. Have you neglected your family because of your use of drugs?* This field is required.
YESNO
79
8. Have you engaged in illegal activities in order to obtain drugs?* This field is required.
YESNO
80
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?* This field is required.
YESNO
81
10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?* This field is required.
YESNO
82
Client Orientation PacketPlease review
83
Your signature below indicates that you have read and understand the client orientation packet including informed consent, payment/fee for service agreements, patient rights and responsibilities, confidentiality statement and CFR 42 PART 2/HIPPA NOTICES. I agree that if I am evaluated by a provisionally licensed/certified provider or any professional who is being supervised for certification/licensure, that this will be explained to me at the time of my evaluation and I have the right to consent or refuse to participate in any video or audio recording used for supervision purposes as explained to me by my evaluator. I certify that I will be participating in this telehealth session from within the state of Iowa and I agree and authorize that my credit card be charged the 125.00 fee for service in order for the service to be scheduled and completed with a qualified substance use disorder assessment provider. * This field is required.Please Sign Below
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