New Patient Packet"*" indicates required fieldsStep 1 of 166%CommentsThis field is for validation purposes and should be left unchanged.Patient InformationWho is your Physician?*Bart Price, MDPetra Travnicek, MD, FACPName* First Middle Last Primary Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Home PhoneCell PhoneEmail* DOB* MM slash DD slash YYYY Sex*MaleFemalePreferred PharmacyPharmacy PhoneMarital StatusSingleMarriedDivorcedWidowedClosest Relative First Last RelationshipRelative PhonePerson Responsible for Bill First Last Referred byYour EmployerEmployer PhoneWhen calling with results, with whom may we leave the information?May we leave the information on a voicemail?YesNoHealthcare advocate First Last Person who will act as your healthcare advocate if there is a need.Advocate PhoneDo you have a signed DNRYesNoCopy of signed DNRAccepted file types: jpg, gif, png, pdf, tiff, Max. file size: 5 MB.Upload a signed copy of your DNR.Do you have advanced directives?YesNoCopy of Advanced DirectivesAccepted file types: jpg, gif, png, pdf, tiff, Max. file size: 5 MB.Insurance and Financial AgreementConsent* Insurance Authorizations and AssignmentI request that payment of authorized Medicare/Other insurance company benefits be made to Manasota Medical Group, LLC for any services furnished to me. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carries any information needed for this or a related Medicare/Other insurance company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be paying for my treatment. (Section 1128B of the Social Security Act and 31 USC 3801-3812 provides penalties for withholding this information.)Type your name for consent*Signature for consentDate of consent* MM slash DD slash YYYY Consent* I have read and understand the above and fully accepts all specified terms therein.INSURANCE PRE-CERTIFICATION: I understand that I am responsible for any required notification needed by my insurance company in order to pay for services rendered. If this is not done, my benefits may be reduced and I am responsible for all non-covered charges. ASSIGNMENT OF BENEFITS: I hereby assign to Manasota Medical Group any and all benefits from my insurance plans or any other protection maintained by the patient. I authorize and direct such benefits to be paid directly to Manasota Medical Group, for services provided. If my insurance plan does not uphold the agreement to pay a claim on my behalf within 30 days of filing, I authorize Manasota Medical Group to file a complaint to the Insurance Commissioner in order to reimburse their offices. FINANCIAL AGREEMENT: The undersigned guarantees prompt payment of all charges for services rendered at time of service. Any unpaid balance due by patient beyond 30 days may be turned over for collection. CONSENT FOR MEDICAL SERVICES: I consent to treatment, diagnostic, and / or therapeutic services as ordered and / or provided by Manasota Medical Group. CANCELLATION POLICY: I understand there is a 24 hour notice to cancel an appointment and that I may be charged for canceling an appointment without notice.Type your name for agreement*Signature for agreementDate of agreement* MM slash DD slash YYYY Please list any major symptoms you are having with your health, new medical problems you have been diagnosed with in the PAST YEAR, or any new concerns you have:Current Medications / Vitamins / Supplements / HerbsMedications*Name of MedicationStrengthTime of Day Taken Add RemoveClick "+" to list more medicationsFood or Drug AllergiesFood or Drug Allergy*AllergyReaction Add RemoveTests & ServicesPlease list the Most Recent date you had any of these tests / servicesAbdominal Aortic UltrasoundAnnual Physical ExamBone DensityCardiac CatheterizationCarotid UltrasoundChest X-RayColonoscopyEchocardiogramEKGEye ExamHearing TestMammogramHemoccult Stool CardsNeuropsychological TestingMini-mental Status ExamPAPPSAStress TestSprirometry Test (Breathing)Upper EndoscopyTB TestOther TestsSpecialty PhysiciansAllergyDr. NameAddressPhoneCardiologyDr. NameAddressPhoneDermatologyDr. NameAddressPhoneGastroenterologyDr. NameAddressPhoneGynecologyDr. NameAddressPhoneHematologyDr. NameAddressPhoneNeurologyDr. NameAddressPhoneNephrologyDr. NameAddressPhoneOncologyDr. NameAddressPhoneOphthalmologyDr. NameAddressPhoneOrthopedicsDr. NameAddressPhoneOtolaryngology (ENT)Dr. NameAddressPhonePain ManagementDr. NameAddressPhonePodiatryDr. NameAddressPhonePrimary CareDr. NameAddressPhonePulmonologyDr. NameAddressPhonePsychiatryDr. NameAddressPhoneUrologyDr. NameAddressPhoneOther type of Physician(s) not listedSpecialtiesDr. NameAddressPhone Add RemovePast Personal Medical HistoryPast Personal Medical History - Section 1 Hypertension Diabetes Angina Heart Attack Rheumatic Fever Valvular Disease Mitral Valve Prolapse Congestive Heart Failure Pulmonary Edema Irregular Rhythm Atrial Fibrillation Pacemaker Asthma Chronic Bronchitis Emphysema (COPD) Pneumonia High Cholesterol Cancer Stroke Cataracts Lenses Glasses Glaucoma TIA COVID-19Please check all that applyHypertensionYear of OnsetAdditional CommentsDiabetesYear of OnsetAdditional CommentsAnginaYear of OnsetAdditional CommentsHeart AttackYear of OnsetAdditional CommentsRheumatic FeverYear of OnsetAdditional CommentsValvular DiseaseYear of OnsetAdditional CommentsMitral Valve ProlapseYear of OnsetAdditional CommentsCongestive Heart FailureYear of OnsetAdditional CommentsPulmonary EdemaYear of OnsetAdditional CommentsIrregular RhythmYear of OnsetAdditional CommentsAtrial FibrillationYear of OnsetAdditional CommentsPacemakerYear of OnsetAdditional CommentsAsthmaYear of OnsetAdditional CommentsChronic BronchitisYear of OnsetAdditional CommentsEmphysema (COPD)Year of OnsetAdditional CommentsPneumoniaYear of OnsetAdditional CommentsHigh CholesterolYear of OnsetAdditional CommentsCancerType of CancerYear of OnsetAdditional CommentsStrokeYear of OnsetAdditional CommentsTIAYear of OnsetAdditional CommentsCOVID-19Year of OnsetAdditional CommentsCataractsYear of OnsetAdditional CommentsLensesYear of OnsetAdditional CommentsGlassesYear of OnsetAdditional CommentsGlaucomaYear of OnsetAdditional CommentsPast Personal Medical History - Section 2 Visual Loss Diabetic Retinopathy Macular Degeneration Color Blind Hearing Loss Seizure Disorder Fainting Spells Loss of Consciousness Obesity Eating Disorder Environmental Allergies Dental Problems Neck Problems Thyroid Disease Hiatal Hernia Reflux Disease (GERD) Peptic Ulcer Bleeding Ulcer H. Pylori Gastritis IBS Chronic Diarrhea Chronic Constipation Diverticulosis Diverticulitis Crohn’s Colitis IleitisPlease check all that applyVisual LossYear of OnsetAdditional CommentsDiabetic RetinopathyYear of OnsetAdditional CommentsMacular DegenerationYear of OnsetAdditional CommentsColor BlindYear of OnsetAdditional CommentsHearing LossYear of OnsetAdditional CommentsSeizure DisorderYear of OnsetAdditional CommentsFainting SpellsYear of OnsetAdditional CommentsLoss of ConsciousnessYear of OnsetAdditional CommentsObesityYear of OnsetAdditional CommentsEating DisorderYear of OnsetType of DisorderAdditional CommentsEnvironmental AllergiesYear of OnsetAdditional CommentsDental ProblemsYear of OnsetAdditional CommentsNeck ProblemsYear of OnsetAdditional CommentsThyroid DiseaseYear of OnsetType of Thyroid DiseaseAdditional CommentsHiatal HerniaYear of OnsetAdditional CommentsReflux Disease (GERD)Year of OnsetAdditional CommentsPeptic UlcerYear of OnsetAdditional CommentsBleeding UlcerYear of OnsetAdditional CommentsH. PyloriYear of OnsetAdditional CommentsGastritisYear of OnsetAdditional CommentsIBSYear of OnsetAdditional CommentsChronic DiarrheaYear of OnsetAdditional CommentsChronic ConstipationYear of OnsetAdditional CommentsDiverticulosisYear of OnsetAdditional CommentsDiverticulitisYear of OnsetAdditional CommentsCrohn’sYear of OnsetAdditional CommentsColitisYear of OnsetAdditional CommentsIleitisYear of OnsetAdditional CommentsPast Personal Medical History - Section 3 Hemorrhoids Abnormal Liver Function Hepatitis Cirrhosis Gallbladder Disease Pancreatitis Osteoarthritis Rheumatoid Arthritis Disc Disease Fractures Spinal Stenosis Osteoporosis Osteoarthritis Motor Vehicle Accident Work Accident Seat Belt Use - Check for YES Anemia Lymphoma White Blood Cell Disorder Impaired Immunity Abn. Bleeding Tendencies Coumadin Use Abn. Kidney Function Kidney Stones Kidney / Bladder Infections Incontinence Skin CancerPlease check all that applyHemorrhoidsYear of OnsetAdditional CommentsAbnormal Liver FunctionYear of OnsetAdditional CommentsHepatitisYear of OnsetAdditional CommentsCirrhosisYear of OnsetAdditional CommentsGallbladder DiseaseYear of OnsetAdditional CommentsPancreatitisYear of OnsetAdditional CommentsOsteoarthritisYear of OnsetAdditional CommentsRheumatoid ArthritisYear of OnsetAdditional CommentsDisc DiseaseYear of OnsetAdditional CommentsFracturesYear of OnsetAdditional CommentsSpinal StenosisYear of OnsetAdditional CommentsOsteoporosisYear of OnsetAdditional CommentsOsteoarthritisYear of OnsetAdditional CommentsMotor Vehicle AccidentYear of OccuranceAdditional CommentsWork AccidentYear of OccuranceAdditional CommentsSeat Belt Use - % of timeWhat percent of the time?Additional CommentsAnemiaYear of OnsetAdditional CommentsLymphomaYear of OnsetAdditional CommentsWhite Blood Cell DisorderYear of OnsetAdditional CommentsImpaired ImmunityYear of OnsetAdditional CommentsAbn. Bleeding TendenciesYear of OnsetAdditional CommentsCoumadin UseYear of OnsetAdditional CommentsAbn. Kidney FunctionYear of OnsetAdditional CommentsKidney StonesYear of OnsetAdditional CommentsKidney / Bladder InfectionsYear of OnsetAdditional CommentsIncontinenceYear of OnsetAdditional CommentsSkin CancerYear of OnsetAdditional CommentsPast Personal Medical History - Section 4 Eczema Psoriasis Seborrhea Hair / Nail Disorders Sexual Dysfunction Infertility Positive TB Test Herpes History of STDs Lyme Disease Chronic Fatigue Syndrome HIV Memory Disturbances Parkinson’s Disease Neuropathy Multiple Sclerosis Tremors Balance Problems Muscle Spasms Restless Leg Syndrome Tendonitis Polymyalgia Gout Any Prosthetic Devices Insomnia Sleep DisorderPlease check all that applyEczemaYear of OnsetAdditional CommentsPsoriasisYear of OnsetAdditional CommentsSeborrheaYear of OnsetAdditional CommentsHair / Nail DisordersYear of OnsetAdditional CommentsSexual DysfunctionYear of OnsetAdditional CommentsInfertilityYear of OnsetAdditional CommentsPositive TB TestYear of OnsetAdditional CommentsHerpesYear of OnsetAdditional CommentsHistory of STDsYear of OnsetAdditional CommentsLyme DiseaseYear of OnsetAdditional CommentsChronic Fatigue SyndromeYear of OnsetAdditional CommentsHIVYear of OnsetAdditional CommentsMemory DisturbancesYear of OnsetAdditional CommentsParkinson’s DiseaseYear of OnsetAdditional CommentsNeuropathyYear of OnsetAdditional CommentsMultiple SclerosisYear of OnsetAdditional CommentsTremorsYear of OnsetAdditional CommentsBalance ProblemsYear of OnsetAdditional CommentsMuscle SpasmsYear of OnsetAdditional CommentsRestless Leg SyndromeYear of OnsetAdditional CommentsTendonitisYear of OnsetAdditional CommentsPolymyalgiaYear of OnsetAdditional CommentsGoutYear of OnsetAdditional CommentsAny Prosthetic DevicesYear of OnsetAdditional CommentsInsomniaYear of OnsetAdditional CommentsSleep DisorderYear of OnsetAdditional CommentsPast Personal Medical History - Section 5 Chronic Headaches Migraines Sleep Apnea History of Radiation Learning Disability Dyslexia ADD / ADHD Anxiety Depression Phobias Manic Depression Bipolar Disorder OCD Adjustment Reactions Suicide Attempts History of Physical Abuse History of Emotional Abuse Past or Present AddictionsPlease check all that applyChronic HeadachesYear of OnsetAdditional CommentsMigrainesYear of OnsetAdditional CommentsSleep ApneaYear of OnsetAdditional CommentsHistory of RadiationYear of OnsetAdditional CommentsLearning DisabilityYear of OnsetAdditional CommentsDyslexiaYear of OnsetAdditional CommentsADD / ADHDYear of OnsetAdditional CommentsAnxietyYear of OnsetAdditional CommentsDepressionYear of OnsetAdditional CommentsPhobiasYear of OnsetAdditional CommentsManic DepressionYear of OnsetAdditional CommentsBipolar DisorderYear of OnsetAdditional CommentsOCDYear of OnsetAdditional CommentsAdjustment ReactionsYear of OnsetAdditional CommentsSuicide AttemptsYear of OnsetAdditional CommentsHistory of Physical AbuseYear of OnsetAdditional CommentsHistory of Emotional AbuseYear of OnsetAdditional CommentsPast or Present AddictionsYear of OnsetType(s) of AddictionPast Personal Surgical History Brain Eyes - Cataracts Sinus Nasal Ear Tonsils Neck Breast-Biopsy Lumpectomy Mastectomy Heart-Bypass Balloon Angioplasty Stents Valves Abdominal-Hernia Repair Appendectomy Gallbladder Stomach Bowel Hemorrhoids Lung Chest Childbirth(s) Pregnancie(s) Hysterectomy Removal of Ovaries Tubal Ligation Kidney Kidney Stones Bladder Prostate Vasectomy Hip Replacement Knee Replacement Joint Replacement Back Disc Cosmetic Carpal Tunnel Aneurysm Repair Varicose Veins Skin OtherPlease check all that applyBrainYearAdditional CommentsEyes - CataractsYearAdditional CommentsSinusYearAdditional CommentsNasalYearAdditional CommentsEarYearAdditional CommentsTonsilsYearAdditional CommentsNeckYearAdditional CommentsBreast-BiopsyYearSide Left RightAdditional CommentsLumpectomyYearSide Left RightAdditional CommentsMastectomyYearSide Left RightAdditional CommentsHeart-BypassYearAdditional CommentsBalloon AngioplastyYearAdditional CommentsStentsYearAdditional CommentsValvesYearAdditional CommentsLungYearSide Left RightAdditional CommentsChestYearAdditional CommentsAbdominal-Hernia RepairYearAdditional CommentsAppendectomyYearAdditional CommentsGallbladderYearAdditional CommentsStomachYearAdditional CommentsBowelYearAdditional CommentsHemorrhoidsYearAdditional CommentsChildbirth(s)Most RecentNumber of ChildbirthsPregnanciesMost RecentNumber of PregnanciesHysterectomyYearAdditional CommentsRemoval of OvariesYearAdditional CommentsTubal LigationYearAdditional CommentsKidneyYearSide Left RightAdditional CommentsKidney StonesYearSide Left RightAdditional CommentsBladderYearAdditional CommentsProstateYearAdditional CommentsVasectomyYearAdditional CommentsHip ReplacementYearSide Left RightAdditional CommentsKnee ReplacementYearSide Left RightAdditional CommentsJoint ReplacementYearSide Left RightAdditional CommentsBackYearSide Left RightAdditional CommentsDiscYearAdditional CommentsCosmeticYearAdditional CommentsCarpal TunnelYearAdditional CommentsAneurysm RepairYearAdditional CommentsVaricose VeinsYearAdditional CommentsSkinYearAdditional CommentsLasik SurgeryYear of OnsetAdditional CommentsOther SurgeriesListSurgery TypeYearAdditional Comments Add RemoveReview of Body SystemsGENERAL Weight Loss Weight Gain Night Sweats Insomnia FatigueCARDIOVASCULAR Chest pain Palpitations Ankle swelling Calf pain Varicose veinsRESPIRATORY Cough Coughing blood Sputum production Wheezing Shortness of breathEAR, NOSE & THROAT Deafness Nose bleeds Runny nose Sneezing Hoarseness Sore throatENDOCRINE Excessive thirst Excessive hair Hair loss Hot flashes Always hot Always cold Erectile dysfunction Infertility Decreased libido Pain during intercourseGASTROINTESTINAL Difficulty swallowing Heart burn Nausea Vomiting Diarrhea Constipation Blood in stools Black stools Abdominal Pain JaundiceNEUROLOGICAL Double vision Headache Dizziness Fainting Weakness Numbness Tingling Ringing in ear TremorsEYES Blurry vision Flashing lights Itchy eyesDERMATOLOGIC Suspicious moles Skin rashes Skin ulcers AcneGYNECOLOGICAL Menopause Irregular periods Breast tenderness Breast lumps Vaginal irritation Vaginal discharge Vaginal drynessUROLOGICAL Painful urination Recurrent infections Frequent urine Blood in urine Incontinence Incomplete bladder Emptying Dribbling Slow urine flowPSYCHOLOGICAL Depression Anxiety Memory loss Hallucinations Suicidal thoughts Frequent mood changesORTHOPEDIC Joint pain Joint swelling Backache Knee pain OtherDescribePlease List Your 5 Personal Health Goals:Family History: Genetic & Acquired PredispositionsHeart DiseaseHistory of Heart Disease Mother Father Sister Brother ChildIs your Mother living? Yes NoMother's age at deathIs your Father living? Yes NoFather's age at deathIs your Sister living? Yes NoSister's age at deathIs your Brother living? Yes NoBrother's age at deathIs your Child living? Yes NoChild's age at deathCancerHistory of Cancer Mother Father Sister Brother ChildType of CancerIs your Mother living? Yes NoMother's age at deathType of CancerIs your Father living? Yes NoFather's age at deathType of CancerIs your Sister living? Yes NoSister's age at deathType of CancerIs your Brother living? Yes NoBrother's age at deathType of CancerIs your Child living? Yes NoChild's age at deathDiabetesHistory of Diabetes Mother Father Sister Brother ChildIs your Mother living? Yes NoMother's age at deathIs your Father living? Yes NoFather's age at deathIs your Sister living? Yes NoSister's age at deathIs your Brother living? Yes NoBrother's age at deathIs your Child living? Yes NoChild's age at deathHypertensionHistory of Hypertension Mother Father Sister Brother ChildIs your Mother living? Yes NoMother's age at deathIs your Father living? Yes NoFather's age at deathIs your Sister living? Yes NoSister's age at deathIs your Brother living? Yes NoBrother's age at deathIs your Child living? Yes NoChild's age at deathCholesterolHistory of High Cholseterol Mother Father Sister Brother ChildIs your Mother living? Yes NoMother's age at deathIs your Father living? Yes NoFather's age at deathIs your Sister living? Yes NoSister's age at deathIs your Brother living? Yes NoBrother's age at deathIs your Child living? Yes NoChild's age at deathAdult Immunization HistoryHepatitis A Received Never Received Would Like to ReceiveYear Received?Hepatitis B Received Never Received Would Like to ReceiveYear Received?T Dap Received Never Received Would Like to ReceiveYear Received?T D Received Never Received Would Like to ReceiveYear Received?Influenza Received Never Received Would Like to ReceiveYear Received?Pneumococcal 13 Received Never Received Would Like to ReceiveYear Received?Pneumococcal 23 Received Never Received Would Like to ReceiveYear Received?Meningococcal Received Never Received Would Like to ReceiveYear Received?Zostavax Received Never Received Would Like to ReceiveYear Received?Shingrix Received Never Received Would Like to ReceiveYear Received?PPD / TB Test Received Never Received Would Like to ReceiveYear Received?COVID-19 Vaccination Received Never Received Would Like to ReceiveWhen was this received?Which Vaccine did you receive?Other Immunization 1 Received Never Received Would Like to ReceiveImmunization TypeYear Received?Other Immunization 2 Received Never Received Would Like to ReceiveImmunization TypeYear Received?Do you have any Food or Drug Allergies?ListAllergyReaction Add RemoveConsumptionDo you drink alcohol?*YesNoAlcohol - How many days per week?Alcohol - How many ounces per day?Does it interfere with work, school, relationships? No YesHow does Alcohol interfere?How you ever received treatment for Alcohol use? Yes NoWhat type of treatment for Alcohol use did you receive?Any relapses after treatment? Yes NoHave you ever used Tobacco?* Yes NoDo you currently use Tobacco? Yes NoWhen did you quitAre you interested in stopping the use of Tobacco? Yes NoWhat efforts have you used to stop?Type of Tobacco Cigarettes Cigars Pipe Dissolvable Products Electronic Cigarettes (Also Referred to as: Vape Pen, etc.) Smokeless Tobacco Products WaterpipesAmount of Tobacco used?If you ever smoked, how many packs per day?How many years did you smoke?Number of PACK YEARSHow many cups of Coffee per day?How many cups of Tea per day?How many 8 oz servings pf Cola/Soda per day?Please describe any “at risk” behaviors, such as car racing, mountain climbing, gliding, etc. or other dangerous work or leisure pursuits or “At risk” sexual practices:Nutrition SurveyHow would you rate your diet in general? Very Healthy Healthy Moderately Healthy Poor Very PoorOn average, what is the total number of servings of fruits and vegetables that you have each day?Do you have food allergies or intolerances?Please describe the healthy and unhealthy aspects of your diet:Please list any improvements would like to make:Would you like more information about nutrition? Yes NoIf Yes, What kind & how can we help you?Use of Complimentary Alternative MedicineAcupuncture Have Used Considered UsingHerbal Remedies Have Used Considered UsingMind & Body Interventions: Meditation / Guided Imaging Hypnosis / Biofeedback / Prayer Have Used Considered UsingHomeopathy Have Used Considered UsingManual Healing Have Used Considered UsingChelation Therapy Have Used Considered UsingNaturopathy Have Used Considered UsingChiropractic / Massage Have Used Considered UsingAroma Therapy Have Used Considered UsingMagnetic Therapy Have Used Considered UsingTherapeutic Touch Have Used Considered UsingOther Type of Therapy Have Used Considered UsingPlease DescribeAccident Prevention & Auto SafetyDo you use protective safety equipment when exercising, performing work duties or other physical activities? Yes No% of time protective equipment used?Number of Auto miles per year?% of time wearing seatbelt?Do you have a tendency to speed? Yes NoDo you have a visual problem? Yes NoDo you have a hearing problem? Yes NoDo you change lanes often? Yes NoAre you distracted by music or conversation? Yes NoDo you use your cell phone while driving? Yes NoMovement / Coordination problem? Yes NoTake medication that may make you too sleepy or impair your driving? Yes NoDo you feel your vehicle is sturdy if in a collision? Yes No# times in the past 10 years you as a vehicle driver were drug or alcohol impaired?# times in the past 10 years have you as a vehicle driver fallen asleep, or were too tired to drive safely?How many people do you think are killed in motor vehicle accidents in the USA yearly?Exercise HabitsPlease describe your exercise(s)TypeFrequency Add RemoveOther types of physical activity:Goals for exercise this year:How will you achieve these goals:SleepPlease check the condition which describes how your sleep is or how it has changed this year: I have no sleep problems difficulty staying asleep or sleep apnea. I have sleep issuesDo you awaken frequently during the night Sleep too much Not enough No YesComments - Awaken frequently during the night Sleep too much Not enoughDo you have difficulty getting up Early morning awakenings Sleepy during the day No YesComments - Difficulty getting up Early morning awakenings Sleepy during the dayDo you have difficulty falling asleep Problems with snoring Sleep walking No YesComments - Difficulty falling asleep Problems with snoring Sleep walkingSocial HistoryAny changes in marital status?Changes in work?New children or grandchildren?New hobbies?Packet ConfirmationCompleted byDate MM slash DD slash YYYY SignatureThe Burns Depression InventorySADNESS: Have you been feeling sad or down in the dumps? Not at All Somewhat Moderate A LotDISCOURAGEMENT: Does the future look hopeless? Not at All Somewhat Moderate A LotLOW SELF ESTEEM: Do you feel worthless or think of yourself as a failure? Not at All Somewhat Moderate A LotINFERIORITY: Do you feel inadequate or inferior to others? Not at All Somewhat Moderate A LotGUILT: Do you get self-critical and blame yourself for everything? Not at All Somewhat Moderate A LotINDECISIVENESS: Do you have trouble making up your mind about things? Not at All Somewhat Moderate A LotIRRITABILITY & FRUSTRATION: Do you feel resentful and angry a good deal of the time? Not at All Somewhat Moderate A LotLOSS OF INTEREST IN LIFE: Have you lost interest in your career, hobbies, family, or friends? Not at All Somewhat Moderate A LotLOSS OF MOTIVATION: Do you feel overwhelmed & have to push yourself hard to do things? Not at All Somewhat Moderate A LotPOOR SELF-IMAGE: Do you think you’re looking old or unattractive? Not at All Somewhat Moderate A LotAPPETITE CHANGES: Have you lost your appetite, or do you overeat or binge compulsively? Not at All Somewhat Moderate A LotSLEEP CHANGES: Do you suffer from insomnia, find it hard to get a good night’s sleep, or are you excessively tired & sleeping too much? Not at All Somewhat Moderate A LotLOSS OF LIBIDO: Have you lost your interest in sex? Not at All Somewhat Moderate A LotHYPOCHONDRIASIS: Do you worry a great deal about your health? Not at All Somewhat Moderate A LotSUICIDAL IMPULSES: Do you have thoughts that life is not worth living or that you might be better off dead? Not at All Somewhat Moderate A LotTotal Score & Degree of DepressionThe Epworth Sleepiness ScaleWatching TV No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingSitting inactive in a public place (e.g. theater or a meeting) No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingAs a passenger in a car for an hour without a break No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingLying down to rest in the afternoon No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingSitting and talking to someone No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingSitting quietly after lunch without alcohol No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingIn a car, while stopped for a few minutes in traffic No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozingTotal ScoreIs there anything else you would like to discuss?
