Now accepting Telehealth appointments. Schedule a virtual visit.

Clinical Questionnaires


 

Document

Pain Questionnaire & WHO-5

Click to download. Standard questionnaire to monitor levels of well-being and pain over time.

PHQ Depression Screen

GAD-7 Anxiety Screen

Mood Disorder Questionnaire

Attention Deficit Disorder Questionnaire

Click to download. This questionnaire allows us to recognize and monitor signs and symptoms of Attention Deficit Disorder.

Stressful Life Events Questionnaire

Audit Alcohol Screener

Urine Drug Screen RX

Click to download. This is our standard prescription for a urine drug screen. Once downloaded and printed out please complete with date, your name, and your date of birth. Most laboratories will then honor the lab requisition. Call office if problems.

New Patient forms

Above click to link to forms we often use at the start and intermittently in the course of care.

 

AGREEMENTS AND CONSENT FORMS

The following two forms
OMS Controlled Substance Use Agreement
General Opiate/Opioid Information Sheet & Consent
are the agreements/consents related to the use of prescribed controlled substances. If you are considering having us prescribe you any controlled substance, please review and be prepared to annually sign the agreement . If you are wanting to be prescribed an opioid such as buprenorphine, morphine, oxycodone, tramadol, etc. please also review and be prepared to sign annually the opioid use agreement:

Location
J. Kimber Rotchford, MD
1233 Lawrence Street, Suite 102 & 301
Port Townsend, WA 98367
Phone: 360-382-6244
Fax: 360-379-1441
Office Hours

Get in touch

360-382-6244