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  • The Patient Health Questionnaire (PHQ-9)

  • Date of Visit
     - -
    2 digit month, 2 digit day, 4 digit year

  • Over the past 2 weeks, how often have you been bothered by any of the following problems?  Rate your answers as follows:

    Not At All = 0

    Several Days = 1

    More than Half the Days = 2

    Nearly Every Day = 3

  • 1. Little interest or pleasure in doing things.
  • 2. Feeling down, depressed or hopeless
  • 3. Trouble falling asleep, staying asleep, or sleeping too much
  • 4. Feeling tired or having little energy
  • 5. Poor appetite or overeating
  • 6. Feeling bad about yourself--or that you're a failure or have let yourself or your family down.
  • 7. Trouble concentrating on things, such as reading the newspaper or watching television
  • 8. Moving or speaking so slowly that other people could have noticed. Or, the opposite--being so fidgety or restless that you have been moving around a lot more than usual.
  • 9. Thoughts that you would be better off dead or of hurting yourself in some way

  • Column Totals --   +     +    +      

  • 10. If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

  • STATEMENT OF UNDERSTANDING

    Assumption of Financial Responsibility for Medical Services

  • I am enrolled in the following insurance plan(s).  Please put self-pay if applicable.

  • I acknowlege that I have voluntarily sought the services of Atkinson Family Practice and Katherine Atkinson, MD, PC, a participating provider.  I accept full responsibility for paying for services provided by Atkinson Family Practice and Katherine Atkinson, MD, PC.  I understand that my insurer will not pay the provider nor reimburse me for the cost of services rendered here, or for any subsequent or ancillary services which the provider may order on my behalf, if this insurance is not truly in effect or if the provider is not considered my primary care physician.  I further acknowledge that it is my responsibility and not the provider's to know what services are covered by my insurer.  I accept full responsibility for paying for services provided if they are not cocered by my insurance.  If the above information changes at any point,  it is my responsibility to notify Atkinson Family Practice.

  • ASSIGNMENT AND RELEASE

  • I certify that I and/or my dependents assign our insurance benefits directly to Katherine J. Atkinson, MD, PC and its employees have the right to disclose my (or my dependents') health care information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits and payments for related services.This consent will remain active unless I cancel it in writing.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • HIPAA

    Contact Information/Privacy Consent
  • Format: (000) 000-0000.
  • May we leave a message and/or medical info to this number?
  • Format: (000) 000-0000.
  • May we leave a message and/or medical information at this number?
  • Format: (000) 000-0000.
  • May we leave a message and/or medical information at this number?
  • Which phone number is primary for messages?
  • How do you want to receive a reminder of an upcoming appointment?
  • Do you have an email address?
  • If so, may our providers contact you with possibly medically-sensitive details?
  • Would you like to receive regular email blasts from our office letting your know of upcoming events and classes, along with healthcare information?

  • Due to HIPAA regulations, we may only discuss health information with people that you have listed below (that includes parents and/or spouses).  

  • Type a question
    Rows

  • Please note that this consent will be valid for one year from date signed.  If your contact information changes before the end date, please complete a new form.  This may be revoked at any time, in writing.  The information is for your protection and we appreciate your cooperation in protecting you and your rights.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: