Preparing for Your Hormone Optimization Consultation - Men
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- Arabella Clark
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1 Preparing for Your Hormone Optimization Consultation - Men Thanks for your interest in our practice. We are excited to help you meet your wellness goals! In preparation for your Hormone Optimization Consultation, Dr. Stafford will review your wellness goals, your medical history, and labs to create a customized plan for you. Please complete the following steps so we may prepare for your visit. Step 1: Complete and Return Forms Print and complete the following forms: Client Profile Consent for Medical Services Medical History Men Consultation Agreement for Hormone Optimization Return your forms to Wellness ReSolutions: Fax to: - or - Scan and to: - or - Mail to: wellness-resolutions@myupdox.com Wellness ReSolutions 6740 Perimeter Dr Ste 300 Dublin OH Step 2: Complete Laboratory Testing When we receive your forms, we will provide you with the necessary lab requisition. Have the labs drawn at the lab of your choice or we can provide the labs for $330. You may wish to consider this option if your insurance plan will not cover these tests, or you have a high deductible insurance plan. We will need the following labs: Complete Blood Count with platelet count Complete Metabolic Panel (CMP) C-Reactive Protein (CRP) DHEA-Sulfate Gamma-Glutamyl Transferase (GGT) Hemoglobin A1c Lipid Panel, [fasting] PSA, Total (prostate specific antigen) Testosterone, Free & Total Thyroid Panel (includes TSH, Free T3, Free T4) Vitamin B12 Vitamin D, 25-OH For valid test results, don t eat or drink anything, except water, for 8 hours prior to the blood draw for this panel. If you are currently taking hormones, labs should be drawn 4 to 5 hours after your morning dose. When we have received all of your information, we will contact you to schedule your appointment. Please contact us with any questions at info@wellness-resolutions.com or We look forward to seeing you soon!
2 Client Profile (Please Print) Name: Preferred Name: Date: Date of Birth: Address: Sex: M F City: State: ZIP: Phone: Cell: How do you prefer to be reached? Home Phone Cell Phone Who do you wish us to contact in an emergency? Name: Relationship: Phone: Healthcare Contacts Primary Care Physician: Pharmacy: Phone: Pharmacy Address: City: Zip: Compounding Pharmacy: Phone: Compounding Pharmacy Address: City: Zip: Client Profile 11/13
3 Consent for Medical Services I, the undersigned, hereby request and consent to the services provided within the scope of practice afforded by licensed health care professionals and clinical staff members of Wellness ReSolutions, LLC ( Wellness ReSolutions ). I understand any recommendations and care received at Wellness ReSolutions are supportive only, and do not substitute for regular medical care. I understand I must continue to see my regular treating health care providers as directed by them and take my regular medications as prescribed. I hereby acknowledge and agree as follows: 1. I acknowledge and agree this agreement has been entered into before Wellness ReSolutions has provided the services specified herein to me. 2. I acknowledge and agree this agreement has not been entered into at a time when I am facing an emergency or an urgent health care situation. 3. The services provided to me may include: a. Evaluation of my medical history, lifestyle, laboratory and other test results; b. Physical examination and diagnostic tests; c. Medical recommendations and management for disease prevention and healthy aging, which may include: nutrition, nutritional supplementation, exercise, lifestyle behaviors, stress management, hormone replacement therapy, and other interventions as indicated by medical history, physical examination and laboratory parameters. 4. I understand I have the right to question any therapy proposed and/or provided by Wellness ReSolutions, and that all my questions will be answered prior to receiving such treatment. I understand I have not been and will not be given a guarantee of beneficial or specific results. I affirm I have and will always, to the best of my ability, disclose my complete current and past medical history to Wellness ReSolutions. I understand this history is essential for Wellness ReSolutions to assess and provide competent care to me. I understand the treatment I receive from Wellness ReSolutions and its health care professionals is in large part based upon my disclosures to them. 5. I have the right to revoke this Consent in writing, at any time, except to the extent Wellness ReSolutions has taken action in reliance on this Consent. 6. I understand I am responsible for full payment of services when they are rendered. 7. I understand health care professionals of Wellness ReSolutions are not participating in any health insurance plans and that Wellness ReSolutions cannot assure me that my insurance company or tax-deductible health plan will reimburse for services provided. 8. I understand that if I am eligible or will become eligible for Medicare Part B Benefits within the next two years, I will need to enter into a Medicare Opt-Out Private Contract before receiving services. 9. By voluntarily signing below, I affirm I have read or have had read to me, and fully understand the information contained in this agreement. I have been advised of the risks and benefits of the services provided to me, and I have had the opportunity to ask questions regarding services. I understand this Consent covers the entire course of treatment provided by Wellness ReSolutions. Client Signature: Date: Client Name (print): Consent Medical Services 7/15
4 Medical History - Men Date Name D.O.B My Primary Health Goals My Current Medical Problems Medication Allergies / Reactions Allergies (e.g. food, environmental) Current Medications - Prescription & Non-prescription (name/dose/reason for use) Current Supplements (name/dose/reason for use) Hospital Admissions / Surgeries Year Illness/Operation Year Illness/Operation
5 2 Screening Tests Test Date Results? Test Date Results? Cholesterol/Lipids Normal Abnormal PSA/Prostate exam* Normal Abnormal Blood Sugar Normal Abnormal Bone Density Normal Abnormal * For PSA/Prostate exam, provide most recent report. Personal and Family History Check boxes if you or a blood relative has suffered any of the following indicate which relative(s), and give details below. Alzheimer s Diabetes Hypertension Osteoporosis Bleeds easily Heart disease Lipid disorder Stroke Cancer (type) HIV / AIDS Mental illness Thyroid disease Family History Details (indicate which disease and which relative affected and explain): Review of Systems Check boxes for any symptom you currently experience and give details. General Excess fatigue Weight loss/gain If checked, list doctor seen, describe condition and duration Weight gained/lost lbs. over months/years (circle one) Easy bruising If yes, do you take blood-thinning medications? Yes No Head/Eyes/Ears/Nose/Throat Vision problems Hearing difficulty/ringing in ears Sinus problems Cardiovascular Chest pain at rest or exercise Heart palpitations Swelling of legs Respiratory Shortness of breath Cough
6 3 Gastrointestinal Constipation Diarrhea Bloating/gas Acidity/reflux Blood in stool Genitourinary Pain on urination Cloudy/bloody urination Frequent urination Difficulty urinating Musculoskeletal Muscle aches or spasm Joint pain Other pain # bowel movement(s)/day: If checked, please rate your pain on a scale from 1-10 (with 1 = mild & 10 = extreme) Indicate affected joints: Details: Neurological Headaches Migraine Tension Other Numbness/tingling Skin Acne/oily skin Dry skin Emotional Depression If yes, are you contemplating suicide? Yes No Anxiety Stress
7 4 Men Symptoms at this time None Mild Moderate Severe Dry skin Dry hair Sleep problems Fatigue Memory loss Concentration loss Anxiety/nervousness Irritability Depression Loss of libido/orgasm Difficulty achieving erection Difficulty maintaining erection Premature ejaculation Decreased morning erections Muscle weakness/loss Muscle and joint pain Loss of masculinity/confidence/aggressiveness Do you have a personal history of: Prostate cancer Yes No Enlarged prostate (BPH) Yes No Abnormal PSA Yes No
8 5 Weight/Height Current weight: Desired weight: Height: Nutrition Provide details about general dietary habits, food intolerances. Ounces per day of caffeinated beverages: Do you consume artificially sweetened drinks or foods? Yes No Exercise/Fitness Activities - Check only one and provide details under Comments. Inactive: no regular physical activity with a sit-down job Light activity: no organized physical activity during leisure time Moderate activity: occasionally involved in activities such as weekend golf, tennis, jogging, swimming, or cycling Heavy activity: consistent lifting, stair climbing, heavy construction, or regular participation in jogging, swimming, cycling or active sports at least three times per week Vigorous activity: participation in extensive physical exercise for at least 60 minutes per session 4 times per week Comments: Sleep Habits Number of hours slept each night: Bedtime: Awaken: Quality of sleep: Excellent Good Poor Number of times you awaken at night: Are you able to return to sleep? Yes No Social Habits Smoking: Never Former Current cigarettes/day: Alcohol: Yes No If Yes, what kind: How many drinks/week: Recreational drugs: Yes No Miscellaneous Include comments on current sources of stress, additional information you would like to share, or to elaborate on previous questions. Client Signature: Date: Client Name (print):
9 Consultation Agreement for Hormone Optimization I authorize payment in the amount of $ to Wellness ReSolutions for the following professional services, to be provided to the client named below: Medical history assessment Review of laboratory results Focused physical examination Clinical recommendations and education regarding hormone balance and replacement therapy. Recommendations will be limited to the following hormones: estrogen, progesterone, testosterone, thyroid, DHEA, and/or melatonin Personal Hormone Optimization Program manual I understand this Initial Consultation is limited to advising me regarding hormone balancing and replacement therapy, and does not include prescriptions or ongoing clinical management of hormone replacement therapy. I understand resources will be used to prepare for my consultation and have been reserved for my scheduled consultation. I agree to pay the full price of the consultation if I miss my scheduled appointment for this consultation without 48 hours cancellation notice. Payment: I authorize one of the following payment methods: Check enclosed (made payable to Wellness ReSolutions, LLC) Visa MasterCard American Express Discover Card Number Exp Date(mm/yy) CCV Name of Cardholder (as it appears on card) Cardholder Signature (if other than client) Client Signature: Date: Client Name (print): Hormone Consult Agreement 7/15
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Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
HORMONE BALANCE QUESTIONNAIRE FOR MEN
HORMONE BALANCE QUESTIONNAIRE FOR MEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a personal
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
DEAN S CHIROPRACTIC CENTER
PATIENT INFORMATION Welcome to Our Office Patient Name of Birth SS# Address City ST Zip Home Phone Cell Work Phone Male Female Email Address Single Married Divorced Widowed Employer Name Occupation Spouse
insurance information
patient information Last Name: First Name: MI: Date of Birth: / / (MM / DD / YYYY) Marital Status: single married other Sex: male female Home Address: City: State: Zip Code: Mailing Address (if different