800.456.1077 Patient and Clinic Demographic This form is for public health assessment use and the demographic data is the only data shared with your incoming medical scribe. This information is not disclosed to anyone other than our internal Scribekick management team. We utilize this assessment form to gain insights internally and to best match you with your medical scribe, while offering you Scribekick training opportunities that you may be interested in having your staff participate. If you have any questions, please feel free to reach out to: jian.massucco@scribekick.comWhich patient group is most important to your practice to begin assessing more routinely now? Adults Seniors Adolescents Children Other What specific health concerns do you want to more systematically ask patients about? Depression and anxiety Healthy eating and physical activity Social support or social isolation Alcohol or substance abuse Sexual activity Tobacco or smoking Personal safety Pain Confidence or ability to manage their own health Quality of life Other health behaviors, risks, or concerns: Does your office have special experience, skill, expertise, and/or training in performing the following services: (Mark all that apply.) Alcohol/Drug Screening Analysis/Lab Urinalysis Ambulatory Detoxification Assessment Case Management Crisis Intervention Individual Counseling GroupCounseling Induction of Buprenorphine Injection of Naltrexone (to treat addiction) Intensive Outpatient (to treat addiction) Psychological Testing Medical Somatic Community Psychiatric Supportive Treatment Health Home Services Comprehensive Care Coordination ☐ Injections (long-acting antipsychotic medications) Mental Health Assessment Partial Hospitalization Pharmacological Management Psychiatric Diagnostic Interview Methadone/Suboxone Do you have a predominant racial or cultural demographic of your patient load? Caucasian Asian Latino Black or African American Native American American Indian Multiple Races Other Is one language predominantly spoken at your clinic? If so, what is that language? How long has your practice been open? Do you have labs, x-ray, and a pharmacy on-site? How close is the nearest pharmacy? Does your clinic offer transportation services? Do the majority of your patients have reliable transportation to and from appointments? What is the primary age range of your patient demographic? Has your patient demographic seen a shift since the start of the COVID-19 pandemic? If so, what has that shift been? Have you seen a lot of patients with COVID-19 since the start of the pandemic? Do you currently offer COVID-19 vaccines or screenings at your clinic? What COVID-19 protocols do you currently have in place? What is the average wait time in your clinic before a patient is seen? How do you typically triage patients (waiting room, nurse intake, provider)? What are the strengths of your practice? What are the weaknesses of your practice? Do you currently partner with other clinics or community stakeholders in your area? Is the geographical area in which you live diverse? If not, what is the predominant socioeconomic status? Do you implement regular training with your staff? If not, what training are you interested in having your staff receive? Have you implemented a Diversity, Equity, and Inclusion training yet (DEI)? Would you be interested in DEI training for your staff? Are the majority of your patients on Medicare, Medicaid, or both? What Insurances do you currently accept? Do you currently have preventative screenings at your clinic? If so, what screenings do you offer? Who primarily greets patients when entering the clinic? Do you consistently remind patients to increase their awareness about specific behaviors and habits that affect their health or chronic conditions? How do you track patient health behaviors over time (e.g., physical activity, smoking, stress, or quality of life)? Do you have a process in place for patient referrals?
