NEW PATIENT PAPERWORK-A

IF THIS FORM IS NOT FILLED COMPLETELY OR THOROUGHLY WE WILL BE UNABLE TO ACCEPT YOU AS A PATIENT AT THIS TIME.

PLEASE REVIEW OUR OTHER GENERAL POLICIES

AND GENERAL INSTRUCTIONS AND MAKE SURE THEY ARE ACCEPTABLE BEFORE PROCEEDING IN THE LINKS BELOW.

GENERAL INSTRUCTIONS JOHN W. GRACE, M.D.,P.A.

READ POLICIES OF JOHN W. GRACE, M.D.,P.A.

IF YOU WOULD PREFER TO PRINT UP YOUR PAPERWORK AND FILL OUT BY HAND PRIOR TO YOUR VISIT FOLLOW AND PRINT THE LINK BELOW. BUT NEW PATIENT PAPERWORK MUST BE COMPLETED PRIOR TO YOUR FIRST VISIT OR YOU WILL BE RESCHEDULED.

NEW PATIENT PAPERWORK IN PDF FORM TO BE PRINTED OUT
IMPORTANT

BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

1. I am NOT currently a danger to myself or others. Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room. The Vines in Ocala, Springbrook Hospital, Shands Hospital.

2. I have read and accept the policies and general instructions of John W. Grace, M.D. above

3. I have insurance that allows me to recieve labs and imagining and I have an active primary care physician that will assist in my care should medical needs arise.

My Products

NEW EVALUATION - SELF PAY RATE$300.00

THIS IS NEW EVALUATION FEE FOR SELF-PAY PATIENTS ONLY. ONLY ENTER FUNDS HERE IF YOU ARE PLANNING ON NOT USING USING YOUR INSURANCE

Total $0.00

Credit Card Details
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LEGAL NAME*

First NameLast Name
GENDER*
PREFERRED METHOD OF BEING ADDRESSED INCLUDING PRONOUNS (IF DIFFERENT FROM ABOVE)
FAMILY PLANNING

Since this office is primarily concerned with medication management and many psychiatric medications carry some risk to the newborn. It is important to avoid pregnancy while on medication if possible.
THIS DOES NOT APPLY TO ME. I am unable to become pregnant at this time either because I am not a biologic female, I have passed menopause, or have had medical conditions or procedures that makes pregnancy impossible.THERE IS VERY LITTLE CHANCE OF BECOMING PREGNANT. Either I am abstinent or practice highly reliable forms of birth control (pills, condoms, vasectomy of partner, etc). I understand the risk of pregnancy on medication and will let you know immediately if something changes in this regard.I AM CURRENTLY PREGNANT OR TRYING TO BECOME PREGNANT.
DATE OF BIRTH*

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ADDRESS*

Street Address

Street Address Line 2

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PRIMARY PHONE NUMBER*

Area CodePhone Number
HOW CAN WE USE THIS PHONE NUMBER?*

May leave confidential voicemails and medical texts at this number.Other
SECONDARY PHONE NUMBER

Area CodePhone Number
HOW CAN WE USE THIS PHONE NUMBER?

May leave confidential voicemails and medical texts at this number.Other
Email
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HOW MAY WE USE THIS EMAIL?

May leave confidential emails and links to this email.Other
Primary Insurance Policy (Policy Number and Group Number) NOTE: WE ARE NO LONGER ACCEPTING NEW PATIENTS WITHOUT SOME FOR OF INSURANCE FOR LABRATORY AND IMAGING*
Secondary Insurance Policy (Policy Number and Group Number)
CURRENT PROVIDERS OF MEDICAL CARE (SPECIALTY AND CONTACT INFO)*
CURRENT HEIGHT WEIGHT RECENT BLOOD PRESSURE AND PULSE. HAVE YOU HAD RECENT LABS OR GENETIC TESTING? IF YES, PLEASE BRING A COPY TO YOUR INITIAL APPOINTMENT. *
EMERGENCY CONTACT INFORMATION. NOTE: IN ADDITION TO THE MEDICAL PROVIDERS ABOVE SOME MEDICAL/PSYCHOTHERAPEUTIC CONFIDENTIAL INFORMATION MAY BE SHARED WITH THESE ENTITTIES FOR SAFETY AND CONTINUITY OF CARE. YOU MAY ALSO LIST OTHER ORGANIZATIONS (ATTORNEYS, INSURANCE COMPANIES, ETC) THAT YOU WISH TO PROVIDE ACCESS TO YOUR RECORDS.
CURRENT MEDICATIONS AND SUPPLEMENTS (DOSE AND HOW TAKEN) IF NONE THEN WRITE "NONE"*
ALLERGIES AND SIGNIFICANT EFFECTS TO MEDICATIONS (MEDICATIONS, FOOD, ENVIRONMENTAL) WHAT HAPPENS? IF NONE THEN WRITE "NONE". *
WHICH OF THE FOLLOWING MEDICAL CONDITIONS HAVE YOU HAD*

NONE OF BELOW APPLY TO MEChronic pain (Describe source below)Head injury with loss of consciousness.DiabetesThyroid ProblemsCOPD (emphysema)Multiple sclerosis.Parkinson’s DiseaseHigh Blood PressureHigh CholesterolChronic Kidney FailureHeart DiseaseGlaucomaRestless LegsFibromyalgiaRheumatoid ArthritisNeuropathyLyme DiseaseLupus
ADDITIONAL MEDICAL CONDITION OR ELABORATION. PLEASE DESCRIBE SOURCES OF CHRONIC PAIN.
SURGICAL HISTORY (WHAT AND WHEN)
PSYCHIATRIC HOSPITALIZATIONS AND PREVIOUS SUICIDE ATTEMPTS (WHEN OCCURRED AND DETAILS REGARDING SUCH) IF NONE TYPE "NONE."*
PREVIOUS PSYCHIATRIC DIAGNOSES AND SIGNIFICANT TREATMENT TRIALS (POSITIVE OR NEGATIVE)
PREVIOUS PSYCHOTHERAPY (WHEN, HOW LONG, AND TYPE OR FOCUS). IF NONE TYPE "NONE". *
FAMILY MEDICAL AND PSYCHIATRIC HISTORY (SUBSTANCE USE, SUICIDE ATTEMPTS AND COMPLETION, GOOD AND BAD TRIALS TO MEDS, RELATION AND NATURE)*
TRAUMATIC EVENTS*

None of these apply to meI am a survivor of horrible childhood abuse.I have experienced severe bullying in childhood.I was sexually assaulted as an adult.I have dealt with physically abusive relationships.I was verbally abused in past relationships.I have had a lot of trauma from medical procedures.I have survived severe motor vehicle accidents.I served in the military and experienced life threatening combat.I have a lost a child.Other
WHICH OF THE ABOVE EVENTS MOST CHANGED YOU? IN WHAT WAYS?
CURRENTLY USING*

NONE OF BELOW APPLY IN THIS CATEGORYAlcoholCaffeineMarijuanaSedatives (valium, xanax, etc)Painkillers (oxycontin, heroin, kratom)STIMULANTS)Other
DESCRIBE FREQUENCY AND AMOUNT OF USE
MISUSED BRIEFLY IN THE PAST*

NONE OF BELOW APPLY IN THIS CATEGORYAlcoholCaffeineMarijuanaSedatives (valium, xanax, etc)Painkillers (oxycontin, heroin, kratom)Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)Other
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
HAD SIGNIFICANT PROBLEMS FROM IN PAST*

NONE OF BELOW APPLY IN THIS CATEGORYAlcoholCaffeineMarijuanaSedatives (valium, xanax, etc)Painkillers (oxycontin, heroin, kratom)Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)Other
DESCRIBE PATTERN AND PROBLES
PROLONGED TREATMENT FOR IN PAST*

NONE OF BELOW APPLY IN THIS CATEGORYAlcoholCaffeineMarijuanaSedatives (valium, xanax, etc)Painkillers (oxycontin, heroin, kratom)Hallucinogens (LSC, PCP, Mushrooms, GHB, Ecstasy, Bath Salts, Huffing)Other
DESCRIBE TREATMENTS
In trying to capture your story it is important to know three things

1. WHERE YOU STARTED? TELL US THE STORY OF THE FIRST PART OF YOUR LIFE.

2. WHERE YOU HAVE BEEN? SUMMARIZE EVERYTHING FROM THE START TO THE CURRENT PICTURE OF YOU.

3. WHERE YOU ARE? DESCRIBE YOUR CURRENT SELF AND HOW LONG YOU HAVE BEEN THAT WAY.
WHERE YOU STARTED: WHAT IS THE STORY OF UPBRINGING AND CHILDHOOD. WHERE WERE YOU BORN? HOW MANY SIBLINGS DID YOU HAVE? WHAT KIND OF WORK DID YOUR PARENTS DO? WHAT WERE YOU LIKE AS A CHILD (OUTGOING, SHY, ATHLETIC)? WERE THERE ANY PROBLEMS AT HOME OR SCHOOL? (BULLYING, POOR ACADEMICS, PHYSICAL, MENTAL, SEXUAL ABUSE)*
WHO YOU WERE: STORY FROM ADOLESCENCE UP UNTIL THIS "VERSION" OF YOU INCLUDING EDUCATION, OCCUPATIONS, RELATIONSHIPS (MARRIAGES, CHILDREN, ECT), TRAUMAS, AND GENERAL PERSONALITY IN THIS PERIOD (SHY, OUTGOING, ETC): *
CURRENT STORY: INCLUDING EDUCATION, OCCUPATIONS, RELATIONSHIPS (MARRIAGES, CHILDREN, ECT), TRAUMAS, GENERAL PERSONALITY IN THIS PERIOD (SHY, OUTGOING, ETC), AND CURRENT LIVING SITUATION. WHO IS YOUR SUPPORT SYSTEM? WHAT IS THE STRENGTHS AND WEAKNESSES OF YOUR SUPPORT SYSTEM?*
THE MOST IMPORTANT THING!

AVOID DESTRUCTIVE IMPULSES THROUGH PLANNING AND ROUTINE

This next section is about how you control destructive impulses.

This may feel like a strange conversation.

Because if you’re reading this, you’re most likely calm. And when we’re calm, and rational, we feel like we should always stay that way. Our “plan” is to remain calm. We say to ourselves—Okay…I’m in control right now. All I have to do is keep an eye on everything and stay in control.

This is NOT a good plan.

Why?

Because rational thought is hard to access in emotional situations. We often lose the ability to be reasonable when we need it most.

We all have buttons, our triggers, and our weakest moments. It is hard to avoid reactionary behavior, destructive impulses when facing these times. We may yell, say things we don’t mean, break things we value…or worse. We often find ourselves regretting our actions during these episodes.

And even if we control our behavior, manage not to be destructive, we still pay a huge price for these contained emotional explosions. We may not sleep, be on-edge, and obsess throughout the night. It can take weeks before our bodies begin the slow process of calming down from a highly triggered event.

So what should we do? We can we do when we can’t count on ourselves to think reasonably.

We should practice a well-rehearsed plan—a rational routine.

Because even though it is hard to access the reasonable part of our brains when we’re emotional, the routine and practiced component is still available. What we keep—even in highly emotional states—is the ability to access well-rehearsed behaviors and routines.

This is why people “practice” in anticipation of emotional situations.

Basketball players shoot free throws.

Soldiers drill.

Politicians rehearse speeches.

They do this so they can implement appropriate behavior in emotional situations without having to try to figure out how to behave in a heightened moment. This lets them stay in control of behavior; lets them return to a calmness faster. The earlier we intervene, the more effective our interventions.

This also let’s us prepare contingency plans unless our first options are effective or available.

I believe in these. I use them on daily basis.

Not only to keep myself calm but to appreciate my life more, to make the most of all of my experiences…even the difficult ones.

Let’s start by looking for triggers and warning signs.
TRIGGERS

What are my triggers? What are the types of situations I’m vulnerable in? These can be confrontations, crowds, authority figures, vulnerability, watching innocents get hurt (children, animals), or others.

For me, I’ve always been triggered when someone acts like something is my responsibility that I have no control over. Not quite sure why, but I find this ridiculously irritating. Another big one of my personal triggers is respect and dignity. Every human being is entitled to it. No one has to earn it. And they can’t lose it. And it always triggers me when I see it being taken, or in some cases, given away. Along those lines, I’m probably triggered by arrogance as well, from individuals and institutions.

Triggers are generally cumulative. More of them on top of one another tend to exaggerate their effect. If you would like you can even rate them on a scale of 1-10 with 1 being the more mild triggers, 10 being the most severe. Its okay if they can’t be quantified at this moment. These will change over time as you identify new ones.

Don’t be surprised if you end up with a lot of these and more over time. That’s okay. That’s the process of learning yourself.

Here are some common triggers.

Confrontations

Crowds

Authority Figures

Arrogance

Disrespect of basic dignity.

Being in Positions of Vulnerability

Medical or dental procedures or interactions

Not being able to assist those I care about

Feeling like I’ve been betrayed

Feeling like I’ve been abandoned

Feeling judged

Being told I’m responsible for a situation I have little control over.

Feeling forced or pressured to do something I don’t want to do.

Others or clarification including if there are more specifics (confrontation with a certain person or type of person, etc).
WHAT ARE MY TRIGGERS?*
WARNING SIGNS

What are my warning signs? How do I automatically react to stressors?Do I pace? Get very quiet? Clench my muscles? Start to have certain images flash?

These aren’t coping skills. These are things you automatically do that don’t seem to help. They are warning signs that you should start using your coping skills.

Personally, I get very quiet, almost feel myself detaching a little from the situation. I also clench my jaw. Over a lifetime I’ve learned, Hey John. This is REALLY bothering you.

What are your warning signs?

Here are some common ones:

Thoughts

My thoughts race.

I start to see images of the past.

Feelings

I feel worthless.

I feel like I’m a burden.

I feels hopeless.

I feel trapped

Physical Sensations

I can’t eat.

I feel flushed, warm, or dizzy.

My heart starts to race.

Behavior

I crave drugs or alcohol

I drink more

I start to pace.

I tense my muscles.

I scratch myself or start to pull my hair.

I can’t sleep.

I get very quiet.
WHAT ARE MY WARNING SIGNS*
COPING SKILLS

These can be thoughts or actions that we do to soothe ourselves. And over a lifetime, you’ll get a lot of these.

Sometimes I go for a walk or a swim.

Sometimes I gently rub the back of my head and say to myself, “It’s okay John. You’re just doing the best you can.”

Sometimes I try to imagine my children living a life similar to mine and imagine what I would say to them in a supportive way. Then I try to say it to myself.

Sometimes I look at the smallest thing in the room that seems peaceful and focus on that for thirty seconds.

Sometimes I remind myself that I don’t need a guarantee that everything will work out to pat myself on the back for making reasonable decisions.

Sometimes I try and remember that one day I’ll look back and miss the challenges and stressors of my life.

Sometimes I lie down on the couch and think to myself that I am living a more luxurious existence than the wealthiest person who was alive 300 years ago.

Sometimes the first ones work. Sometimes you have to move on. Coping is a fluid experience that requires moving on if something isn’t working.

What are your coping skills?
WHAT ARE MY COPING SKILLS?*
COPING PLACES AND PEOPLE

Sometimes we have to lean on people or places to bring us back to being calm…a spouse, a friend, a park, or even a coffee house.

Strangely, I found McDonalds very comforting in medical school. They were always open, easy to find, and similar inside.

I’ve moved on to parks as I’ve gotten older.

People can also help to calm us. Friends, family, coworkers, and acquaintances can serve this role in different ways.

One thing about people, is never count on them to always be available. They may be preoccupied, unable to assist in the moment, or unavailable. They are part of a plan but can never be guaranteed to be available at every moment. Of course, you could make that statement for every coping skill, that is why is so important to have many.

Try to be specific…and if available give contact information.
WHAT ARE MY COPING PLACES? WHO ARE MY COPING PEOPLE? *
CHANGING OUR ENVIRONMENT TO AVOID DESTRUCTIVE IMPULSIVITY

We can also adjust our environment to reduce destruction. We can remove firearms if they are more likely to do us harm than help us at the current time. We can minimize large quantities of dangerous pills. We can remove alcohol from our homes.

If I find myself getting too hooked on a game or phone application, I’ll remove it from my phone and give my brain a rest from that impulsivity.

These are ways we can make our environment safer.
WHAT CAN I DO TO MAKE MY ENVIRONMENT SAFER?*
WHAT APPROACH DO I WANT TO TAKE TO MY CARE?*

"I am most interested in my short-term quality of life (next 6 months to 2 years). I understand this means I may end up taking medications or making choices that might result in decrease in the overall length of my life or produce significant side effects later.""Living longer and healthier overall means the most to me. I understand that some treatments might not be appropriate and am willing to have to some decrease quality of life in the short-term for more long-term health benefits down the road. I understand this may mean starting to come down or decrease some medications associated with long term risk, particularly sedating or sleeping agents."
WHY ARE YOU SEEKING TREATMENT AT THIS TIME? WHAT ARE YOUR GOALS FOR THIS EPISODE OF CARE. WE TRY TO DO UPDATES/ TREATMENT PLANS AT LEAST A FEW TIMES A YEAR, MORE IF NECESSARY. SO THINK OF THE NEXT 3-6 MONTHS WHAT WOULD YOU LIKE YOUR GOALS/FOCUS OF CARE TO BE? TRY TO MAKE THEM REALISTIC, MEASURABLE, AND ACHIEVABLE*
WHO REFERRED OR SUGGESTED YOU COME AND WHY? IF NO ONE REFERRED YOU THEN WRITE "SELF"*
REVIEW OF SYMPTOMS WHICH OF THE FOLLOWING SYMPTOMS CURRENTLY APPLY? (EXPLAIN IN NEXT BOX)*

NONE OF BELOW APPLYWeight lossWeight gain.FeverFatigueChanges in your skinChanges in nailsOpen sores or rashesItchingLumps or moles that are new or changed?HeadachesHead TraumaSeizuresGlaucomaVision problemsHearing problemsRinging in earsRoom spinningEar PainNose bleedRunny noseBleeding or soreness in your mouth or tongueSore throatHoarsenessSwollen glandsLumps or nodules in breastsDischarge from the breastsChest painsHeart beating too fastShortness of breathAny wheezingSwelling in the feetCoughsProblem swallowingIndigestion or heartburnNausea and vomitingDiarrheaConstipationIncrease or decreased appetiteChanges in your stoolIncreased or Decreased UrinationProblems urinatingChange in color or smell or urineChange in frequency of urineUrinating at nightDrinking a lotIncontinenceChanges in periodsVaginal dischargeThere is a history of pregnancyThere is a chance I'm currently pregnantSexual DifficultiesImpotenceErection ProblemsDischarge from penisPain in JointsSwelling of feet or legsMy fingers change color in coldSeizuresTremorsWeakness or unusual sensationsTremorsEasy bruising or bleedingIntolerance of heat or coldBlanking out, where you didn't remember where you were or how you gotthereTraveled out of the country
PLEASE ELABORATE ON ANY ABOVE CHECKED BOXES
WHICH DESCRIBE YOUR MENTAL HEALTH SYMPTOMS?*

None of these apply to meGENERAL TRAITS: I am easily overwhelmed.GENERAL TRAITS: I can manage a lot of things but have a history of overextending myself.GENERAL TRAITS: I tend to take care of others and neglect myself.HOARDING :I have a real problem holding onto things excessively, to the point that it affects my space or lifestyle.OBSESSIONS: I have really clear and specific obsessions (with germs, numbers, rituals, etc) that take up at least thirty minutes of my day and sometimes many more.OBSESSIONS: I tend to think in circles when nervous.PANIC ATTACKS: I have had panic attacks.SOMATIZATION: I have had a lot of physical complaints that seem related to emotional state.MANIA: I have a family hx. of bipolar disorder.MANIA: I have had really clear mania in past. Periods where sleep was not required without any feelings of tired. This was not related to either taking or withdrawing from any substances or medication.MANIA: I have a history of clear seasonality to mood.MANIA: I have had possible mania or cyclic irritability.MANIA: I am a night owl.MAJOR DEPRESSIVE EPISODE: I have had multiple periods of depression lasting at least two weeks during which I had five of the following nine symptoms (sadness, loss of interest, weight change, sleep problems, agitation, fatigue, feeling worthless or guilty, concentration difficulties, thoughts of death or suicide)GENERALIZED ANXIETY DISORDER: I tend to worry about everything for at least the last six months. This worrying affects at least three of following (energy, concentration, muscle tension, sleep, restlessness)ADULT ATTENTION DEFICIT DISORDER: I have trouble focusing throughout life including paying attention throughout childhood in school. This affects me in at least six of the following ways (fail to give close attention to details, trouble holding attention, often doesn't seem to listen, trouble finishing tasks due to getting distracting, trouble organizing tasks, reluctance to do things that require consistent focus (taxes, etc), often loses things, easily distracted, often forgetful)PSYCHOSIS: I nearly always have some level of reality disturbance in the form of paranoia or hallucinations.PSYCHOSIS: I occasionally have disturbance in reality.PSYCHOSIS: My mind sometimes plays tricks.PSYCHOSIS: I have hallucinations.ANGER PROBLEMS: I have a problem with temper.ANGER PROBLEMS: I overreact to stress.ANGER PROBLEMS: I overreact to small insults.ANGER PROBLEMS: I am triggered by disrespect.ANGER PROBLEMS: I am triggered by authority figures.ANGER PROBLEMS: I can have severe anger during decompensation.PTSD-Intrusion symptoms: Some of the traumatic events I've lived through still haunt me in at least one of following ways (recurrent memories, dreams, flashbacks, or marked distress when I am exposed to reminders of them.)PTSD-Avoidance symptoms: Some of the traumatic events I've lived through still cause me to avoid things (people, places, subjects) that mind remind me of the traumas.PTSD-Alteration symptoms: Some of the traumatic events I've lived through have changed the way I think in at least one of the following ways (can't remember details of traumatic events, see myself in a persistent negative way, always feeling guilty, detached, or unhappy).PTSD-Hyperarousal symptoms: Some of the traumatic events I've lived through have made me hyper-alert causing at least one of the following (irritability, reckless behavior, jumpiness, concentration difficulties, sleep problems)Other
ELABORATE OR CLARIFY ANY OF THE ABOVE SYMPTOMS.
(VOCATIONAL HISTORY) WHAT KIND OF WORK HAVE YOU DONE THROUGH LIFE AND ARE CURRENTLY DOING? IF YOU ARE DISABLED FROM WORK, HOW LONG AND FROM WHAT CONDITIONS? (IF ADDRESSED ABOVE SAY "SEE ABOVE")*
EDUCATION HISTORY: DESCRIBE HOW FAR YOU WENT IN SCHOOL, AREAS OF STUDY, STRENGTHS AND STRUGGLES(IF ADDRESSED ABOVE SAY "SEE ABOVE")*
MILITARY HISTORY: BRANCH OF THE SERVCE DATES OF SERVICE RANK AT DISCHARGE TRAUMATIC EVENTS DURING SERVICE DISCIPLINARY ACTIONS DURING SERVICE(IF ADDRESSED ABOVE SAY "SEE ABOVE")*
RELATIONSHIP HISTORY: DESCRIBE SIGNIFICANT PAST RELATIONSHIPS INCLUDING MARRIAGES, CHILDREN AND FRIENDSHIPS(IF ADDRESSED ABOVE SAY "SEE ABOVE")*
LEGAL HISTORY (ARRESTS, CHARGES, WHEN OCCURRED). IF NONE TYPE "NONE."(IF ADDRESSED ABOVE SAY "SEE ABOVE")*
ALTERNATIVE REMEDIES TRIED IN PAST*

None of theseVitamin B12Vitamin DDeplinSam-E,5-HTTP,CoQ10,Fish Oil,Flaxseed Oil,Melatnonin,St. John’s WortOther
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
COGNITIVE ENHANCERS TRIED IN THE PAST*

None of theseDonepezil (Aricept)Rivastigmine (Exelon)Galantamine (Razadyne)Dextromethorphan / Quinidine (Neudexta)Other
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
ATTENTION DEFICIT MEDICATIONS TRIED IN THE PAST*

None of theseMethylphenidate (Ritalin, Concerta)Amphetamine and dextroamphetamine (Adderall)Dextroamphetamine (Dexadrine)Phentermine (Adipex-P, Lomaira)Lisdexamfetamine (Vyvanse)Modafinil (Provigil)Armodafinil (Nuvigil)Atomoxetine (Strattera)ClonidineGuanfacine (Tenex)Other
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
SLEEP AGENTS TRIED IN PAST*

None of theseTrazadone (Desryl),MelatoninZolpidem (Ambien)Zaleplon (Sonata)Eszopiclone (Lunesta)lTemazepam (Restoril)BenadrySuvorexant (Belsomra)Doxepin (Sinequan)Other
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
MOOD STABILIZERS TRIED IN THE PAST*

None of theseLithiumValproic Acid (Depakote)Lamotrigine (Lamictal)Carbemazipine (Tegretol),Haloperidol (Haldol)Ziprasidone (Geodon)Olanzipine (Zyprexa)Quetiapine (Seroquel)Aripiprazole (Abilify)).Oxcarbazepine (Trileptal)Levetiracetam (Keppra)Topiramate (Topamax)Gabapentin (Neurontin)Pregabalin LyricaBrexpiprazole (Rexulti)Lurasidone(Latuda)Pimavanserin (Nuplazid)Cariprazine (Vraylar)Other
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
ANXIETY TREATMENTS TRIED IN THE PAST*

None of these(Lorazepam (Ativan)Alprazolam (Xanax)Diazepam (Valium)Buspirone (Buspar)Triazolam (Halcyon)Clonidine (Catapras)Prazosin (Minipres)BaclofenTizanidine (Zanaflex)Hydroxizine (Vistaril)Other
DESCRIBE SIGNIFICANT RESPONSES TO ABOVE
DEPRESSION TREATMENTS TRIED IN THE PAST*

None of theseKetamine derivativesElectroconvulsive TherapyTranscranial Magnetic TherapyVagus Nerve StimulationDeep Brain StimulationBotox InjectionsFluoxetine (Prozac)Paroxetine (Paxil)Sertraline (Zoloft)Venlafaxine (Effexor)Mirtazapine (Remeron)Buproprion (Wellbutrin, Zyban)Citalopram (Celexa)E-Citalopram (Lexapro)Amitryptiline (Elavil)Nortriptiline (Pamelor)Clomipramine (Anafranil)Doxepin (Sinequan)Vilazadone (Viibryd)Vortioxetine (Trintellix)Phenylzine (Nardil)Other
HOW WILL OUR PROGRESS BE MEASURED:

We are going to be using a number of evidence-based psychological scales to track progress. The first three scales are specific to anxiety, depression, and post-traumatic stress disorder. The last scale is a general scale that measures how we handle emotions and stress.

GAD-7: TRACKS SEVERITY OF ANXIETY

This scale measures generalized worry and anxiety.

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all	Several Days	More than half of Days	Nearly Every Day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

PHQ-9

This scale tracks the severity of depression

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

	Not at all	Several Days	More than half of Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself

PCL

This scale tracks the severity of post traumatic stress disorder

In the past month, how much were you bothered by: *

	Not at all	A little bit	Moderately	Quite a bit	Extremely
Repeated, disturbing, and unwanted memories of the stressful experience?
Repeated, disturbing dreams of the stressful experience?
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Avoiding memories, thoughts, or feelings related to the stressful experience?
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Trouble remembering important parts of the stressful experience?
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Blaming yourself or someone else for the stressful experience or what happened after it?
. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Irritable behavior, angry outbursts, or acting aggressively?
Taking too many risks or doing things that could cause you harm?
Being “super alert” or watchful or on guard?
Feeling jumpy or easily startled?
Having difficulty concentrating?
Trouble falling or staying asleep?

OPTIONAL

This next scale is optiona for initial evaluations. The Difficulties in Emotion Regulation Scale (DERS) is an instrument measuring emotion regulation problems.

Please indicate the response that is most true for you.

	Almost Never	Sometimes	About half the time	Most of the Time	Almost Always
I am clear about my feelings
I pay attention to how I feel
I experience my emotions as overwhelming and out of control
I have no idea how I am feeling
I have difficulty making sense out of my feelings
I am attentive to my feelings
I know exactly how I am feeling
I care about what I am feeling
I am confused about how I feel
When I’m upset, I acknowledge my emotions
When I’m upset, I become angry with myself for feeling that way
When I’m upset, I become embarrassed for feeling that way
When I’m upset, I have difficulty getting work done
When I’m upset, I become out of control
When I’m upset, I believe that I will remain that way for a long time
When I’m upset, I believe that I’ll end up feeling very depressed
When I’m upset, I believe that my feelings are valid and important
When I’m upset, I have difficulty focusing on other things
When I’m upset, I feel out of control
When I’m upset, I can still get things done
When I’m upset, I feel ashamed with myself for feeling that way
hen I’m upset, I know that I can find a way to eventually feel better
When I’m upset, I feel like I am weak
When I’m upset, I feel like I can remain in control of my behaviours
When I’m upset, I feel guilty for feeling that way
When I’m upset, I have difficulty concentrating
When I’m upset, I have difficulty controlling my behaviours
When I’m upset, I believe that there is nothing I can do to make myself feel better
When I’m upset, I become irritated with myself for feeling that way
When I’m upset, I start to feel very bad about myself
When I’m upset, I believe that wallowing in it is all I can do
When I’m upset, I lose control over my behaviours
When I’m upset, I have difficulty thinking about anything else
When I’m upset, I take time to figure out what I’m really feeling
When I’m upset, it takes me a long time to feel better
When I’m upset, my emotions feel overwhelming

BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

1. I am NOT currently a danger to myself or others. Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room. The Vines in Ocala, Springbrook Hospital, Shands Hospital.

2. I have read and accept the policies and general instructions of John W. Grace, M.D.

3. I understand that I am not a patient of the office until after Dr. Grace and I agree after our first visit to enter into a doctor-patient relationship and I will have to seek treatment elsewhere.
BY SIGNING BELOW I ATTEST THE ABOVE IS ACCURATE AND I AM FAMILIAR WITH AND ACCEPT THE OFFICE CURRENT POLICIES *

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