AUTHORIZATION TO OBTAIN HEALTHCARE RECORDS

 +
to disclose  health information, regarding the person referenced herein to the above named facility, all of my medical records including any specially protected records such as those related to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, HIV or Hepatitis infections for the purpose of provision of medical treatment  and  healthcare. I understand that the information disclosed pursuant to the this authorization may be subject to re-disclosure by the the recipient and that it is no longer protected by the federal privacy regulations.
 
Information to be disclosed to: tf (or Top Flight) Medical Group, P O Box 292796 Nashville, Tennessee 37229, lise llc  370 Doolittle RD Woodbury, Tennessee 37190 whose phone contact number is 877.743.2646 and whose electronic mail addresses (email addresses)  are: tfmedicalgroup@gmail.com and lise@lisehealth.com and whose fascimile is 877.472.3945 or 877.743.2646
 
Purpose of use of this information: Assistance in providing medical care/continuity of medical care. I understand that unless I revoke the authorization earlier, this authorization will automatically expire 12 months after the date that this authorization is signed. Further, should I desire to revoke this authorization, I must send written notice to Top Flight Medical Group / lise llc at the address shown above
 
I understand that I am not  required to sign tjhis authorizataion.  Generally, Top Fight Medical  Group/ lise llc  will not  condition treatment, payment, enrollment or  any eligibility for benefits on whether I provide this information, except in situations  in which doing so might more than usually lead to  otherwise avoidable harm
 
Use of copies: A copy of this authorization may be utilized with the same effectiveness as an original.
 *
LEGIBLE SIGNATURE OF PATIENT/CLIENT OR REPRESENTATIVE *
clear
Please  complete this  form   within  5 DAYS of  your  next  visit  with us.  Please  arrive  at  least  5 minutes  prior to your scheduled appointment  time  so that  we make maximize our  opportunity    with you at  your  visit. (PLEASE NO PERIODS OR COMMAS,   OR  OTHER  PUNCTUATION. PLEASE SEPARATE WORDS  BY SPACES)
 +
IF IT IS FELT TO BE NECESSARY, DO YOU AGREE TO HOLDING YOUR VISIT VIA VIDEO-CHAT (VIRTUAL, TELEMEDICINE, TELEHEALTH)) *

REMEMBER TO BRING ALL PAIN MEDICATIONS USED WITHIN THE LAST 30 DAYS REGARDLESS OF WHO PRESCRIBED THE MEDICATION (INCLUDING PILLS, PATCHES, BOTTLES, BOXES) PILLS SHOULD BE IN THE BOTTLES THAT THEY CAME IN OR IN YOUR DAILY MEDICATION PLANNER AND UNUSED PATCHES SHOULD BE IN THE APPROPRIATE BOX OR IN PLANNER - EVEN IF EMPTY AND BRING JOURNAL UNLESS SENT ELECTRONICALLY

Appointment Information

PLEASE LET US KNOW THE REASON FOR THIS VISIT *

THOUGHTS ABOUT YOUR CURRENT TREATMENT

HAVE YOU BEEN COMPLETELY VACCINATED AGAINST COVID-19 *
HAVE YOU TESTED POSITIVE FOR COVID- 19 AND THEN HAD A FOLLOW-UP TEST THAT WAS NEGATIVE *
HAVE YOU HAD EXPOSURE TO ANYONE WHO HAS ACTIVE POSITIVE COVID-19 WITHIN THE LAST 7 DAYS *

TREATMENT: NOT RELATED TO WHY YOU SEE OUR GROUP SINCE LAST VISIT

ANY PROCEDURES/ OR SURGERY SINCE LAST  VISIT WITH US *

IF NO NEW COMPLAINT(S) SKIP TO REGULAR COMPLAINT SECTION PLEASE

NEW COMPLAINT(S) - Ones that have never been discussed here before

PLEASE ANSWER THIS QUESTION SERIES IF YOU HAVE A NEW COMPLAINT, IF NONE TYPE IN NA OR NONE

DESCRIBE THE  QUALITY OF YOUR  NEW DISCOMFORT
(CHECK ANY THAT  APPLY)
 

NEW TRAUMA (PROVIDE ANSWERS AS NEEDED)

HAVE YOU HAD  ANY  NEW TRAUMA  WITH NEW COMPLAINTS RELATED TO THE TRAUMA SINCE YOUR LAST  VISIT *
IF YOU HAVE  HAD  NEW TRAUMA SINCE LAST VISIT DO YOU BELIEVE THAT IT IS THE CAUSE OF YOUR NEW COMPLAINT
FOR THE NEW COMPLAINT DID YOU GO TO AN EMERGENCY DEPARTMENT  OR ANOTHER  PROVIDER SINCE  LAST VISIT 

SECTIONS FOR ONGOING COMPLAINT(S) THAT WE ARE ALREADY TREATING

IF MEDICATIONS WERE ADJUSTED AT YOUR LAST VISIT WAS THE ADJUSTMENT HELPFUL

 *

COMPLETE THIS PART IF YOU HAD ANY INJECTION WITH US AT LAST VISIT

ROUTINE TESTS

NEW IMAGING

HAVE YOU HAD  IMAGING DONE  THAT OUR GROUP SENT YOU FOR OR RELATED TO THE REASON OUR GROUP SEES YOU SINCE YOUR LAST VISIT (X-ray, MRI,  etc) *

WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS

CONCERNS FOR WHICH WE ARE ALREADY SEEING YOU FOR HERE

IS YOUR  USUAL PAIN LEVEL ON MOST DAYS BETTER NOT CHANGED OR WORSE SINCE LAST VISIT *
IS THE AMOUNT OF  PAIN  RELIEF YOU ARE NOW OBTAINING FROM YOUR CURRENT PAIN RELIEVER (S)  ENOUGH TO MAKE A REAL DIFFERENCE IN YOUR LIFE *
DESCRIBE THE  QUALITY OF YOUR  DISCOMFORT
(CHECK ANY THAT  APPLY) *
 
WHAT WAS YOUR  PAIN LEVEL AT ITS AVERAGE DURING THE PAST WEEK *
WHAT WAS  YOUR PAIN LEVEL ON AVERAGE DURING THE PAST 30 DAYS *

COMPLAINT 2 - BY-PASS/SKIP ANYTHING THAT IS NOT RELEVANT IN THIS SECTION

IS YOUR  USUAL PAIN LEVEL ON MOST DAYS BETTER NOT CHANGED OR WORSE SINCE LAST VISIT
IS THE AMOUNT OF  PAIN  RELIEF YOU ARE NOW OBTAINING FROM YOUR CURRENT PAIN RELIEVER (S)  ENOUGH TO MAKE A REAL DIFFERENCE IN YOUR LIFE
DESCRIBE THE  QUALITY OF YOUR  DISCOMFORT
(CHECK ANY THAT  APPLY)
 
WHAT WAS YOUR  PAIN LEVEL AT ITS WORST DURING THE PAST WEEK
WHAT WAS  YOUR PAIN LEVEL ON AVERAGE DURING THE PAST WEEK

COMPLAINT 3 - BY PASS ANYTHING THAT IS NOT RELEVANT IN THIS SECTION

DESCRIBE THE  QUALITY OF YOUR  DISCOMFORT
(CHECK ANY THAT  APPLY)
 
IS YOUR  USUAL PAIN LEVEL ON MOST DAYS BETTER NOT CHANGED OR WORSE SINCE LAST VISIT
IS THE AMOUNT OF  PAIN  RELIEF YOU ARE NOW OBTAINING FROM YOUR CURRENT PAIN RELIEVER (S)  ENOUGH TO MAKE A REAL DIFFERENCE IN YOUR LIFE
WHAT WAS YOUR  PAIN LEVEL AT ITS WORST DURING THE PAST WEEK
WHAT WAS  YOUR PAIN LEVEL ON AVERAGE DURING THE PAST WEEK

COMPLAINT 4 - BY PASS ANYTHING THAT IS NOT RELEVANT IN THIS SECTION

IS YOUR  USUAL PAIN LEVEL ON MOST DAYS BETTER NOT CHANGED OR WORSE SINCE LAST VISIT
IS THE AMOUNT OF  PAIN  RELIEF YOU ARE NOW OBTAINING FROM YOUR CURRENT PAIN RELIEVER (S)  ENOUGH TO MAKE A REAL DIFFERENCE IN YOUR LIFE
DESCRIBE THE  QUALITY OF YOUR  DISCOMFORT
(CHECK ANY THAT  APPLY)
 
WHAT WAS YOUR  PAIN LEVEL AT ITS WORST DURING THE PAST WEEK
WHAT WAS  YOUR PAIN LEVEL ON AVERAGE DURING THE PAST WEEK
FAMILY HISTORY OF DRUG USE *
AGE *
HISTORY OF PRE-ADOLESCENT SEXUAL ABUSE *
PSYCHOLOGICAL DISEASE *

BEHAVIORAL MATTERS

PLEASE CHECK ONLY ONE CHOICE FOR WHAT APPLIES TO YOU (THERE ARE 4 CHOICES FOR EVERY STATEMENT) YOU SHOULD CHECK A BOX FOR EACH NUMBER *

REMEMBER TO BRING ALL MEDICATIONS THAT WE ARE PRESCRIBING AND ANY NEW MEDICATIONS USED WITHIN THE LAST 30 DAYS (INCLUDING PILLS, PATCHES, BOTTLES, BOXES) PILLS SHOULD BE IN THE BOTTLES THAT THEY CAME IN OR IN YOUR DAILY MEDICATION PLANNER AND UNUSED PATCHES SHOULD BE IN THE APPROPRIATE BOX OR IN PLANNER AND BRING JOURNAL UNLESS SENT ELECTRONICALLY

HAVE YOU EVER FELT THAT YOU SHOULD CUT DOWN ON YOUR DRINKING *
HAVE PEOPLE ANNOYED YOU BY CRITICIZING YOUR DRINKING *
HAVE YOU EVER FELT BAD OR GUILTY ABOUT YOUR DRINKING *
HAVE YOU EVER HAD A DRINK FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR TO GET RID OF A HANGOVER *

Over the last two weeks, how often have you been bothered by any of the following problems- select one choice only

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 FIDGETY OR RESTLESS THAT YOU HAVE BEEN MOVING AROUND A BIT MORE THAN USUAL *
THOUGHTS THAT YOU WOULD BE BETTER OFF DEAD, OR OF HURTING YOURSELF ON SOME WAY *

TOBACCO PRODUCTS

ARE YOU CURRENTLY SMOKING  OR  USING  TOBACCO PRODUCTS *

ACTIVITIES AND OCCUPATIONAL

TREATMENT FOR YOUR CONDITIONS HERE SINCE LAST VISIT

HAVE YOU HAD  ANY  PHYSICAL THERAPY  OR OTHER TREATMENT SINCE  YOUR  LAST VISIT  WITH US *
IF YOU HAVE HAD PHYSICAL THERAPY OR OTHER TREATMENT SINCE YOUR LAST VISIT, 1-WERE YOU GIVEN A HOME EXERCISE PROGRAM TO DO, 2-ARE YOU DOING IT AND 3-HAS IT HELPED

MEDICATIONS

ANY NEW MEDICATIONS SINCE YOUR LAST VISIT *
ARE YOU TAKING  YOUR MEDICATIONS  THE WAY THAT THEY ARE PRESCRIBED *
IF YOU ARE TAKING OPIOID PAIN MEDICATIONS (EXAMPLE- HYDROCODONE /OXYCODONE/MORPHINE) DO YOU FEEL THAT YOU ARE IN GOOD CONTROL OF THEM *
IF YOU ARE TAKING OPIOID PAIN MEDICATIONS DO YOU FEEL THAT YOU NEED THEM TO IMPROVE FUNCTION AND QUALITY OF DAILY LIVING *

CURRENT DAILY ACTIVITIES

INDICATE WHETHER  YOUR FUNCTION  WITH THE CURRENT PAIN RELIEVERS IS BETTER, THE SAME, OR WORSE SINCE THE  LAST  TIME  YOU WERE HERE *
 BETTERSAMEWORSE
PHYSICAL FUNCTIONING
FAMILY RELATIONSHIPS
SOCIAL RELATIONSHIPS
MOOD
SLEEP PATTERNS
OVERALL FUNCTIONING

please answer the questions choosing one selection only

HOW OFTEN DO YOU HAVE MOOD SWINGS? *
HOW OFTEN HAVE YOU FELT A NEED FOR HIGHER DOSES OF MEDICATION TO TREAT YOUR PAIN? *
HOW OFTEN HAVE YOU FELT IMPATIENT WITH YOUR DOCTORS? *
HOW OFTEN HAVE YOU FELT THAT THINGS ARE JUST TOO OVERWHELMING THAT YOU CAN'T HANDLE THEM? *
HOW OFTEN IS THERE TENSION IN THE HOME? *
HOW OFTEN HAVE YOU COUNTED PAIN PILLS TO SEE HOW MANY ARE REMAINING? *
HOW OFTEN HAVE YOU BEEN CONCERNED THAT PEOPLE WILL JUDGE YOU FOR TAKING PAIN MEDICATION?  *
HOW OFTEN DO YOU FEEL BORED? *
HOW OFTEN HAVE YOU TAKEN MORE PAIN MEDICATION THAN YOU WERE SUPPOSED TO *
HOW OFTEN HAVE YOU WORRIED ABOUT BEING LEFT ALONE *
HOW OFTEN HAVE YOU FELT A CRAVING FOR MEDICATION? *
HOW OFTEN HAVE OTHERS EXPRESSED CONCERN OVER YOUR USE OF MEDICATIONS? *
HOW OFTEN HAVE ANY OF YOUR CLOSE FRIENDS HAD A PROBLEM WITH ALCOHOL OR DRUGS *
HOW OFTEN HAVE OTHERS TOLD YOU THAT YOU HAD A BAD TEMPER? *
HOW OFTEN HAVE YOU FELT CONSUMED BY THE NEED TO OBTAIN PAIN MEDICATION *
HOW OFTEN HAVE YOU RUN OUT OF MEDICATION EARLY? *
HOW OFTEN HAVE OTHERS KEPT YOU FROM GETTING WHAT YOU DESERVE *
HOW OFTEN, IN YOUR LIFETIME, HAVE YOU HAD LEGAL PROBLEMS OR BEEN ARRESTED *
HOW OFTEN HAVE YOU ATTENDED AA OR NA MEETINGS *
HOW OFTEN HAVE YOU BEEN IN AN ARGUMENT THAT WAS SO OUT OF CONTROL THAT SOMEONE GOT HURT *
HOW OFTEN HAVE YOU BEEN SEXUALLY ABUSED *
HOW OFTEN HAVE OTHERS SUGGESTED THAT YOU HAVE AN ALCOHOL OR DRUG PROBLEM *
HOW OFTEN HAVE YOU HAD TO BORROW PAIN MEDICATIONS FROM YOUR FAMILY OR FRIENDS *
HOW OFTEN HAVE YOU BEEN TREATED FOR AN ALCOHOL OR DRUG PROBLEM *

WE DO NOT CURRENTLY PRESCRIBE OPIOIDS FOR LONG-TERM MANAGEMENT

In the past 30 days how often have you had trouble with thinking clearly or had memory problems? *
In the past 30 days, how often do people complain that you are not completing necessary task? (I.e., doing things that need to be done, such as going to class, work or appointments) *
In the past 30 days, however often had you had to go to someone other than your prescribing physician to get sufficient pain relief from medications? (i.e., another doctor, emergency room, friends, street sources) *
In the past 30 days, how often have taken your medications differently from how they are prescribed? *
In the past 30 days how often have you seriously thought about hurting yourself *
In the past 30 days how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)? *
In the past 30 days, how often have you been in an argument? *
In the past 30 days, how often have you had trouble controlling her anger (e.g., road rage, screaming, etc.)? *
In the past 30 days, how often had you needed to take pain medications belonging to someone else *
In the past 30 days, how often have you been worried about how you're handling your medications *
In the past 30 days, how often have others been worried about how you're handling your medications? *
In the past 30 days, how often have you had to make an emergency phone call or show up at the clinic without an appointment *
In the past 30 days, how often have you gotten angry with people *
In the past 30 days, how often have you had to take more of your medication than prescribed? *
In the past 30 days, how often have you borrowed pain medication from someone else *
In the past 30 days, how often have you used your pain medication for symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve stress) *
In the past 30 days, how often have you had to visit the emergency room *

CONTROL OF MEDICATIONS AND LEGAL COMPLIANCE SINCE LAST VISIT

USED ANY ILLEGAL DRUGS OR TAKEN ANY MEDICATION NOT PRESCRIBED FOR YOU SINCE LAST VISIT? IF YES ENTER  DATE  AND TIME   *

ALLERGIES TO MEDICATIONS

SIDE EFFECTS TO MEDICATIONS BUT NOT TRUE ALLERGIES

FAMILY MEDICAL HISTORY

DAILY GENERAL SYMPTOMS

TODAY DO YOU HAVE  ANY NEW
WHICH OF THE FOLLOWING DO YOU USE OR HAVE ACCESS TO *

Remember, we recommend that you never discuss your medication or treatment with other persons in the facility except the providers . Also, keep your belongings, including your medications, documents, etc with you or your trusted guardian or representative at all times. We will never take your medications from your (or their(s)) view. If one of of team/ staff, asks for you to give them your medication(s) before you enter the exam room or counting /monitoring area - DO NOT. Please make provider aware if this happens.

BY CHECKING  THE  BOX,  I HEREBY AUTHENTICATE AND  ACKNOWLEDGE AS TRUE, THAT THIS MEDICAL FORM IS CORRECT, HAS BEEN  REVIEWED BY ME, THE CLIENT, AND IS AN ACCEPTABLE REPRESENTATION OF MY CURRENT   APPLICABLE HEALTH STATUS AS  OF  TIME OF  COMPLETION.  WILL ALERT THE PROVIDER ON THE VISIT DATE IF THERE ARE ANY   CHANGES.

Also, please  TYPE and sign below with your mouse if your are on computer, or with  a stylus or your finger if you are completing this form from a compatible mobile device. PLEASE MAKE SURE SIGNATURE IS LEGIBLE *
clear

REMEMBER TO BRING ALL PAIN MEDICATIONS USED WITHIN THE LAST 30 DAYS (INCLUDING PILLS, PATCHES, BOTTLES, BOXES) PILLS SHOULD BE IN THE BOTTLES THAT THEY CAME IN OR IN YOUR DAILY MEDICATION PLANNER AND UNUSED PATCHES SHOULD BE IN THE APPROPRIATE BOX OR IN PLANNER AND BRING JOURNAL UNLESS SENT ELECTRONICALLY

WE APPRECIATE YOUR VISIT AND RESPECT YOUR TIME. WE HAVE FOUND THAT BY ELECTRONICALLY SCHEDULING FOLLOW-UP VISITS WITH OUR GROUP, WE CAN BE MORE EFFICIENT WITH THE USE OF TIME. IN MOST CASES, YOUR NEXT VISIT WITH US WILL BE SCHEDULED VIA EMAIL OR OTHER ELECTRONIC RESOURCES

PELASE BRING ALL NEWLY PRESCRIBED MEDICATION(S) SINCE YOUR LAST VISIT WITH US

WOMEN IF THERE IS ANY CHANCE THAT YOU ARE CURRENTLY PREGNANT TELL US NOW PLEASE

 *
IF YOU ARE GOING TO NEED A WORK OR SCHOOL NOTE FROM US AFTER YOUR VISIT WITH US , PLEASE CHECK THE APPROPRIATE BOX

WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS

BE SURE TO GET GREEN CHECK MARK AND COPY YOUR REFERENCE NUMBER DOWN AFTER COMPLETING THE FORM

"lives serving lives"

property of top flight medical group, lise llc all rights reserved do not duplicate any part

Powered byFormsiteReport abuse
 'lives serving lives'
please contact us via our website: skyraisers.wixsite.com/tfmgglobal email: tfmg@flightmedicalgroup.com/ lise llc 
or phone: 877.743.2646