Name* First Middle Last Date of Birth:* Month Day Year Consent for Telemedicine Appointment* I have read and agree that: Telemedicine is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telemedicine consultation with a Provider, details of your medical or health history and personal health information may be discussed using interactive audio, video, and/or other telecommunications technology, and the Provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or other legal document. The telemedicine services you receive from Emed Multispecialty Group are not intended to replace a primary care physician relationship, be your permanent medical home, or be used during a medical emergency. If you think you are having a medical emergency, you should dial 911 immediately. You should seek emergency help or follow-up care when recommended by a provider, symptoms worsen, or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended. We may make arrangements for follow-up care either through Emed Multispecialty Group, your primary care provider, or other health care providers. If the transmission fails during your telemedicine consultation with a provider, then every attempt will be made to contact you to help you get reconnected. You will have direct access to Healow and Emed Multispecialty Group services to follow-up on medication reactions, side effects, or other adverse events. Among the benefits of Emed Multispecialty Group via Healow is improved access to health care professionals and convenience. However, there are potentials risks associated with the use of telemedicine. These risks include, but are not limited to: 1. In some instances, the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.) 2. Delays in evaluation or treatment could occur due to failure of the electronic equipment; 3. In some instances, a lack of access to all of your medical records could result in adverse drug reactions or allergic reactions or other judgment errors; 4. Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information. I, (Patient Name) have read the information, or have had it read to me, and have received a copy of this agreement. I understand my responsibilities and agree to the above conditions while receiving opioid medication. NO SHOW/LATE CANCELLATION APPOINTMENT POLICY* I Have Read & Agree that: We, at Emed Multispecialty Group, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). For your convenience, there are several options available to cancel your appointment. (1) Call us at (904) 513-3240 during our normal business hours. (2) If you call after hours, our after-hour phone service is available to assist you. (3) Download the HEALOW app for access to cancel or make an appointment. To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, we will attempt to send an appointment reminder call/text at least (1) business day prior to your scheduled appointment. Please ensure we have your updated phone number on file. However, it is the responsibility of the patient to arrive for their appointment on time. PLEASE REVIEW THE FOLLOWING POLICY: • Please cancel your appointment with at least a 24 hours’ notice: There is a waiting list to see the Providers at Emed and whenever possible, we like to fill cancelled spaces to shorten the waiting period for our patients. • If less than a 24-hour cancellation is given this will be documented as a “No-Show” or “Late Cancellation” appointment and will be assessed a $20.00 no show or late cancellation fee. I have read and understand Emeds No Show/Late Cancellation Appointment Policy and understand my responsibility to plan appointments accordingly SignatureWhat treatment are you seeking today?* Pain Medication (Opiate Treatment) Narcotic Addiction (Buprenorphine/Suboxone) Anxiety Medication ADD/ADHD Medication Pain Management QuestionnaireHow long have you had your current pain?* Days Weeks Months Years Out of 10, what is your pain level today?*1 - not bad at all23456 - severe78 - very severe910 - worst pain possiblePlease choose the areas that hurt:*please, only choose top 2 areas that hurt. Head Neck Middle Back Lower Back Shoulder Elbow Hand Arm Wrist Hip Leg Knee Ankle Foot Information about your HEAD pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your NECK pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your MIDDLE BACK pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your LOW BACK pain:Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your SHOULDER pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your ELBOW pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your HAND pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your ARM pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your WRIST pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your HIP pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your LEG pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your KNEE pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your ANKLE pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Information about your FOOT pain:Which side is your pain?* Left Right Both Have you ever had surgery on this area?* Yes No Is this pain the result of a major trauma or accident?* Yes No Does your pain prevent you from doing daily activities?* Yes No How would you describe your pain?* Sharp Achy Constant Throbbing Dull Stabbing Does your pain radiate?* Legs Arms Back Chest Neck Does anything make your pain worse?* Bending Prolonged Walking Prolonged Standing Prolonged Sitting Heavy Lifting Does anything improve your pain?* Rest Position changes Stretching Medications Physical Therapy Is there tingling/numbness?* Yes No Is there swelling in the area?* Yes No Is the pain worse with movement?* Yes No Are you currently taking medications for this?* Yes No Narcotic addiction treatmentDo you have a history of narcotic abuse/opioid use?* Yes No How long have you been on treatment for this condition?* Never Days Months Years Are you currently experiencing any symptoms of withdrawal?* No Anxiety Depression Vomiting Muscle cramps Runny nose Shaking Are you currently receiving counseling* Yes No Anxiety QuestionnaireHow long have you experienced these symptoms?* Days Weeks Months Years Currently taking medications?* Yes No How often do you experience these symptoms?* Constant Frequent Infrequent Check all of the symptoms you feel when you are anxious:* Fatigue Agitation Feeling overwhelmed restlessness Sweating Excessive worry Insomnia Nausea Palpitations Poor concentration Chest Pain Please choose any associated conditions you have:* Borderline personality Disorder Substance abuse Psychomotor retardation Alcoholism Obsessive-compulsive disorder Post-traumatic stress disorder COPD Asthma Diabetes Hyperthyroidism Drug misuse or withdrawal Withdrawal from alcohol Chronic pain Bipolar What makes your anxiety worse?* medications non-compliance with treatment hormonal imbalances psychomotor retardation stress low self-esteem abuse of alcohol or recreational drugs serious/chronic illness chronic pain traumatic events What relieves your anxiety? Rest psychotherapy cognitive behavioral therapy relaxation techniques ADD/ADHD QuestionnaireWhat behavioral problems are you experiencing?* Cannot concentrate impulsive aggression foul language Do you have associated hyperactivity?* Yes No Do you have difficulty concentrating?* Yes No Are you easily distracted?* Yes No Do these symptoms affect your daily routine?* Yes No Are you currently taking medication for ADD/ADHD?* Yes No