Golden Home Health Care is bringing the Golden Standard back to you Home Care

T (734) 422 6340
Email: mail@goldenhomecares.com

Golden Home Health Care
13407 Farmington Road #209 Livonia, MI, US

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Patient Form

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Patient Info
Insurance Info
Anxiety
Depression
Bi-Polar Mania
ADHD
Panic Attack

Patient Info

First Name*

Middle Name

Last Name*

Date of Birth*

Street Address*

Address Line 2

City*

State*

Zip Code*

Home Phone Number

Mobile Number

Work Phone Number

Email Address*

Insurance Info

Please complete this as accurately as possilbe, as incomplete information may affect your insurance company's coverage of your claim and result in a higher out of pocket cost.

Have you been referred through an Employee Assistance Program (EAP)?*

Yes

No

Full name of insured party

Insured party's date of birth

Insured party's employer

(Enter N/A if not using insurance)

Insurance/managed care company name

(Enter N/A if not using insurance)

Insurance company phone number*

(Enter N/A if not using insurance)

Insurance company fax number*

(Enter N/A if not using insurance)

Insurance member ID/number

(Enter N/A if not using insurance)

Insurance group name or number

(Enter N/A if not using insurance)

Insurance company address for claim

(Enter N/A if not using insurance)

Do you have secondary insurance?

Yes

No

Anxiety

Do you Feel nervous, anxious or on edge?*

0

Not being able to stop or control worrying*

0

Worrying too much about different things*

0

How often do you have trouble relaxing*

0

Being so restless that it is hard to sit still*

0

Becoming easily annoyed or irritable*

0

Feeling afraid as if something awful might happen*

0

Depression

Lately, would you say that you’ve felt sad or empty most of the time?*

0

Have you turned down invitations to take part in social engagements recently because of disinterest, even when the activities were ones that you used to engage in regularly?*

0

Have you lost interest in eating?*

0

If not, do you feel like you’re eating all the time?*

0

Have your friends or family made comments lately such as, “What’s wrong?” or “Are you okay?”*

0

Have you recently gone through a breakup, lost a job, or experienced the death of a loved one?*

0

Do you find it hard to enjoy things that once seemed like fun or interesting?*

0

Have you been experiencing noticeable changes in your sleeping habits lately? Do you have trouble sleeping? Do you want to sleep all the time or have trouble “getting moving?”*

0

Do you find that it takes an unusually great amount of effort for you to concentrate on even simple tasks recently?*

0

Do you find yourself feeling overwhelmingly guilty or down on yourself?*

0

Do you find yourself preoccupied with thoughts about your own death lately, either by suicide or some other means?*

0

Do you feel depressed in spite of pleasant events or outcomes?*

0

Have you lost interest in your normal level of sexual activity or taking part in sexual activity all together?*

0

Do you find it extremely difficult to perform at your daily routine because of fatigue or lack of energy?*

0

Have you been experiencing some or all of these things to a degree that makes it nearly impossible to function?*

0

Bi-Polar Mania

Feeling unusually “high” and optimistic OR extremely irritable*

0

Unrealistic, grandiose beliefs about one’s abilities or powers*

0

Sleeping very little, but feeling extremely energetic*

0

Talking so rapidly that others can’t keep up*

0

Racing thoughts; jumping quickly from one idea to the next*

0

Highly distractible, unable to concentrate*

0

Impaired judgment and impulsiveness*

0

Acting recklessly without thinking about the consequences*

0

Delusions and hallucinations (in severe cases)*

0

ADHD

Difficulty paying attention to details and tendency to make careless mistakes in school or other activities; producing work that is often messy and careless*

0

Easily distracted by irrelevant stimuli and frequently interrupting ongoing tasks to attend to trivial noises or events that are usually ignored by others*

0

Inability to sustain attention on tasks or activities*

0

Difficulty finishing schoolwork or paperwork or performing tasks that require concentration*

0

Frequent shifts from one uncompleted activity to another*

0

Procrastination*

0

Disorganized work habits*

0

Forgetfulness in daily activities (for example, missing appointments, forgetting to bring lunch)*

0

Failure to complete tasks such as homework or chores*

0

Frequent shifts in conversation, not listening to others, not keeping one's mind on conversations, and not following details or rules of activities in social situations*

0

Fidgeting, squirming when seated*

0

Getting up frequently to walk or run around*

0

Running or climbing excessively when it's inappropriate (in teens this may appear as restlessness)*

0

Having difficulty playing quietly or engaging in quiet leisure activities*

0

Always being 'on the go'*

0

Often talking excessively*

0

Panic Attack

Do you have shortness of breath or hyperventilation*

0

Have you been experiencing heart palpitations or a racing heart*

0

Have you been experiencing chest pain or discomfort*

0

Have you been experiencing trembling or shaking*

0

Have you been experiencing choking feeling*

0

Have you been feeling unreal or detached from your surroundings?*

0

Have you been experiencing uncontrollable sweating*

0 - 0

Have you been experiencing nausea or upset stomach*

0 - 0

Have you been feeling dizzy, light-headed, or faint*

0 - 0

Have you been experiencing numbness or tingling sensations*

0 - 0

Have you been experiencing hot or cold flashes*

0 - 0

Have you been experiencing fear of dying, losing control, or going crazy*

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