Download New Patient/Client Information Form

Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
Patient Information
Please Print Clearly
Patient/Client Information:
Last Name:
Home Phone:
Date: ___________
First Name:
Work Phone:
Social Security#:
Age:
M.I.:
Cell Phone:
Birthdate:
Marital Status:
Home Address:
Apt.#:
City:
State:
Mailing Address:  same as home address
Street:
City:
Fax:
Zip Code:
Apt.#:
State:
P.O. Box#:
Zip Code:
Email Address:
Occupation/Student:
Employer/School:
Employer’s Address:
Apt/Suite#:
City:
State:
Family Information:
Spouse’s Last Name:
Zip Code:
First Name:
Spouse’s Occupation:
M.I.:
Spouse’s Work Phone:
Children (Please include Name/Sex/Age):
If Patient is Under 18 Years of Age:
Mother’s Name:
Phone Number:
Father’s Name:
Phone Number:
Emergency Contact: Someone who does not live with you.
Last Name:
First Name:
Relation:
Address:
Apt/Suite#:
City:
Home Phone:
Referral Information:
Last Name:
State:
Zip Code:
Work Phone:
Cell Phone:
First Name:
Relation:
Address:
City:
May we thank him/her?  Yes  No
Apt/Suite#:
State:
Zip Code:
Current Medical Information:
Primary Care Physician:
Specialty:
Address:
Apt/Suite#:
City:
State:
Phone Number:
Fax Number:
Zip Code:
Last Seen:
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com
Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
Are you currently undergoing medical therapy? If yes, please fill out the next 5 lines.
 No  Yes
Reason:
Last Name:
First Name:
Specialty:
Address:
Apt/Suite#:
City:
State:
Phone Number:
Fax Number:
Zip Code:
Last Seen:
Are you currently in counseling/psychotherapy? If yes, please fill out the next 5 lines.
 No  Yes
Reason:
Last Name:
First Name:
Specialty:
Address:
Apt/Suite#:
City:
State:
Zip Code:
Medical History:
 Please check if you do not feel comfortable filling this section out in writing. If checked, Dr. Miller will go over this
information with you privately, however, it will be counted as part of your session time.
What are the desired outcomes or goals of your work with Dr. Miller?:
Have you seen other professionals for this purpose?  No  Yes, please fill out below.
Last Name:
First Name:
Specialty:
Address:
City:
State:
Phone Number:
Zip Code:
Last Seen:
Are there any issues or conditions (physical, mental, emotional, social, spiritual or behavioral) that may have a bearing on
what you want to accomplish here?
 No  Yes, please explain:
Any prior experience with relaxation therapy, biofeedback, hypnotherapy, meditation
or other Mind/Body approaches?  No  Yes, please describe:
Describe any past hospitalizations, please include dates (except childbirth, tonsils and
minor problems):
Phone Number:
Fax Number:
Last Seen:
What is the general state of your health?:
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com
Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
Describe any current physical or other health problems:
List all current medications and dosages:
(Use separate sheet if needed)
Please Describe:
How do you rate your diet and nutritional habits?  Excellent  Good  Fair  Poor
How do you rate your exercise program?
What is your routine?
 Excellent  Good  Fair  Poor
How do you rate your relationships with others?
Current Issues:
 Excellent  Good  Fair  Poor
How do you rate your sleep?
 Excellent  Good  Fair  Poor
sleep?__________________ Number of hours sleep per night?__________
Do you use:
 Alcohol
Amount used:
 Cigarettes
Amount used:
 Caffeine
Amount used:
 Other drugs
Amount used & Type:
Quality of
Patient Health History
Pregnancy: Please list all pregnancies, miscarriages and abortions.
Year:
Gender:
Complications:
Year:
Year:
Gender:
Gender:
Complications:
Complications:
Year:
Gender:
Complications:
Serious Illnesses/Injuries/Surgeries:
Year:
Condition:
Outcome:
Year:
Condition:
Outcome:
Year:
Condition:
Outcome:
Year:
Condition:
Outcome:
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com
Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
Occupational Concerns: Please check if your work exposes you to any of the following
 Stress
 Hazardous Substances
 Heavy Lifting
 Repetitive Motion
 Inadequate Safety/Protective Gear?
Has there been significant alcohol or drug usage in your immediate family or family of
origin?  No  Yes, please explain:
Has there been a history of depression or other psychiatric disorder in your family?  No  Yes, please explain:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
Allergies
List any allergies to medications, or significant side effects:
Family Health History:
Father:
Age Now:
State of Health:
Age at Death:
Significant Illnesses/Cause of Death:
Mother:
Age Now:
State of Health:
Brothers:
Significant Illnesses/Cause of Death:
Age Now:
State of Health:
Age at Death:
Age at Death:
Significant Illnesses/Cause of Death:
Age Now:
State of Health:
Age at Death:
Significant Illnesses/Cause of Death:
Sisters:
Age Now:
State of Health:
Age at Death:
Age Now:
State of Health:
Age at Death:
Significant Illnesses/Cause of Death:
Age Now:
State of Health:
Age at Death:
Significant Illnesses/Cause of Death:
Age Now:
Children:
State of Health:
Significant Illnesses/Cause of Death:
Age Now:
State of Health:
Age at Death:
Age at Death:
Significant Illnesses/Cause of Death:
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com
Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
Children
Age Now:
State of Health:
Age at Death:
Significant Illnesses/Cause of Death:
Age Now:
State of Health:
Age at Death:
Significant Illnesses/Cause of Death:
Have any of your biological relatives had any of the following?:
 Arthritis, gout
Relation:
 Asthma, allergies
Relation:
 Cancer
Relation:
 Chemical Dependency
Relation & Type:
 Diabetes
Relation & Type:
 Heart Disease/High Cholesterol
Relation:
 High Blood Pressure
Relation:
 Kidney Disease
Relation:
 Stroke/TIA
Relation:
 Osteoporosis
Relation:
 Other:
Please fill out the following only if you are a minor or are seeing Dr. Miller for ADD/ADHD:
Prenatal and Birth Events:
Your Parents Attitude Toward their Pregnancy with You:
Pregnancy Complications:
Any Birth Problems, Forceps, or Complications:
Sleep Behavior: (sleepwalking, nightmares, recurrent dreams, current problems)
School History: please bring copies of school report cards and any state, national or special testing that has been performed.
Last Grade Completed:
Last School Attended:
Average Grades Received:
Learning Strengths:
Specific Learning Disabilities:
Behavior Problems in School:
Teacher’s Comments:
Biological Mother’s History:
Highest Grade Completed:
Marriages:
Learning Problems:
Behavior Problems:
Medical Problems:
Childhood Atmosphere:
Has Mother Ever Undergone Any Type of Psychotherapy?  No  Yes, please explain:
Mother’s Alcohol/Drug Use History (what & when):
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com
Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
Have any of your mother’s biological relatives ever had any learning problems or psychiatric problems including such
things as alcohol/drug abuse, depression, anxiety, suicide attempts, and/or psychiatric hospitalizations?  No  Yes,
please explain:
Biological Father’s History:
Highest Grade Completed:
Marriages:
Learning Problems:
Behavior Problems:
Medical Problems:
Childhood Atmosphere:
Has Father Ever Undergone Any Type of Psychotherapy?  No  Yes, please explain:
Father’s Alcohol/Drug Use History (what & when):
Have any of your father’s biological relatives ever had any learning problems or psychiatric problems including such things
as alcohol/drug abuse, depression, anxiety, suicide attempts, and/or psychiatric hospitalizations?  No  Yes, please
explain:_________________________________________________________________________
Biological Father’s History:
Highest Grade Completed:
Marriages:
Learning Problems:
Behavior Problems:
Medical Problems:
Childhood Atmosphere:
Has Father Ever Undergone Any Type of Psychotherapy?  No  Yes, please explain:
Father’s Alcohol/Drug Use History (what & when):
Have any of your father’s biological relatives ever had any learning problems or psychiatric problems including such things
as alcohol/drug abuse, depression, anxiety, suicide attempts, and/or psychiatric hospitalizations?  No  Yes, please
explain:
Agreement Page
My work with most people does not involve the use of medication – in fact, many who are using medications find they are
able to reduce or stop. Sometimes, however, the judicious use of selected agents may be valuable. What are your feelings
about using medications?
 Absolutely no medication under any circumstances
 Very resistant to medications, but would consider
 Would prefer not to use medication, but open to them if necessary
 Do not have a set opinion toward medication
 Believe strongly that I need medication
Focus of Treatment:
I understand that Dr. Miller offers counseling, psychotherapy, relaxation therapy, stress management, hypnotherapy and
other modalities of Mind/Body treatment and counseling. I am not consulting him in expectation of a complete physical
examination, diagnostic workup or general medical therapy, and I understand that the services he offers are not intended as a
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com
Emmett E Miller, MD
Mind/Body Medicine . EMDR . Stress
Management
substitute for primary medical care. I also acknowledge that the practice of medicine is not an exact science and that Dr.
Miller has made no guarantees to me as to the result of treatments.
Financial Agreement:
I understand that I am financially responsible for all charges whether or not they are covered by insurance. Unless otherwise
agreed upon in writing, I agree to pay for each service at the time it is rendered. In the event of default, I agree to pay all
costs of collection and reasonable attorney’s fees. I hereby authorize Emmett E. Miller, M.D. to release all information
necessary to secure the payment of benefits. For services provided by Emmett E. Miller, M.D., I authorize payment of
medical benefits to Emmett E. Miller M.D. I further agree that a photocopy of this agreement shall be as valid as the
original. I authorize the use of this signature on all insurance submissions.
Insurance Agreement:
If you are accessing your mental health benefits and are a beneficiary of a managed care plan, by signing this statement you
give permission to Emmett E. Miller M.D. to share clinical information as necessary to obtain benefit coverage; whether
that is written, telephonic or by fax transmission. Furthermore, you give permission to Emmett E. Miller, M.D. to mail
billing and/or correspondence to your home or office. If you have medical insurance and mental health benefits are not
available, or have been exhausted, you are responsible for payment at our usual and customary rate.
Signature:
Date:
Signature of Parent if Client is a Minor:
Authorization to Release Medical Information:
I hereby request and authorize discussion and release of all information including medical records, X-rays, history and
findings and prognosis pertaining to the medical condition of services rendered, or treatment given to me by the physicians,
healthcare practitioners, hospital, clinic or medical facility I have identified.
Signature:
Date:
(Signature of patient/spouse/parent/conservator/guardian or patient’s representative)
Rev 10/1/11
P.O. Box 803 Nevada City, CA 95959 (530) 478-1807 phone (530)-478-0160 fax
www.DrMiller.com