INTERNAL MEDICINE CENTRE Female Patient Questionnaire & History. Date of Birth: Age : Occupation: Home Address: Home Phone: Cell Phone:
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1 G rapevwne INTERNAL MEDICINE CENTRE Female Patient Questionnaire & History Name: --,----,- -=--,-- ---,=,,-,- Today's Date: 11.3$1) (First) IM~dle) Date of Birth: Age : Occupation: Home Address: City: State: Zip: Home Phone: Cell Phone: Work: Address: May we contact you via E Mail? ( ) YES ( ) NO In Case of Emergency Contact: Relationship: Home Phone: Cell Phone: Work: Primary Care Physician's Name: Phone: Address: Marital Status (check one): Address City 51,He Zip () Married ( ) Divorced ( ) Widow ( ) living with Partner ( ) Single In the event we cannot contact you by the mean's you've provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment. Spouse's Name: Relationship: Home Phone: Cell Phone: Work: Social: ( ) I am sexually active. ( ) I want to be sexually active. ( ) I have completed my family. ( ) My sex has suffered. ( ) I haven't been able to have an orgasm. Habits: ) I smoke cigarettes or ciga rs per day. ) I drink alcoholic beverages per week. ) I drink more than 10 alcoholic beverages a week. ) I use caffeine a day. New Female Patie nt Package Page Number: 2 Revision Date
2 INTERNAL MEDICINF CE NTR E Medical History Any known drug allergie s: _ Have you ever had any issues with anesthesia? ( ) Yes ( ) No If yes please explain: Medications Currently Taking: Current Hormone Replacement Therapy: Past Hormone Replacement Therapy: Nutritional/Vitamin Supplements: Surgeries, list all and when: Last menstrual period (estimate year if unknown): Other Pertinent Information: Preventative Medical Care : Medical Illnesses: ( ) Medlcal/GYN Exam in the last year. ( ) High blood pressure. ( ) Mammogram in the last 12 months. ( ) Heart bypass. ( ) Bone Density in the last 12 months. ( ) High cholesterol. ( ) Pelvic ultrasound in the last 12 months. ( ) Hypertension. High Risk Past Medical/Surgical History: ( ) Heart Oisease. ( ) Breast Cancer. ( ) Stroke and/or heart attack. ( ) Uterine Cancer. ( ) Blood clot and/or a pulmonary emboli. ( ) Ovarian Cancer. ( ) Arrhythmia. ( ) Hysterectomy with removal of ovaries. ( ) Any form of Hepatitis or HIV. ( ) Hysterectomy only. ( ) lupus or other auto immune disease. ( ) Oophorectomy Removal of Ovaries. ( ) Fibromyalgia. Birth Control Method: ( J Menopause. ( ) Hysterectomy. ( ) Tubal Ligation. ( ) Birth Control Pills. ( ) Vasectomy. ( ) Other: ( ) Trouble pa ssing urine or take Flomax or Avodart. ( J Chronic liver disease (hepatitis, fatty liver, cirrhosis). ( ) Diabetes. ( ) Thyroid disease. ( J Arthritis. ( ) Depression/anxiety. ( ) Psychiatric Disorder. ( ) Cancer (type) : Year: New Female Patient Package Page Number: 3 Revision Date
3 ~biote, BHRT Checklist Name: Date: .: Symptom (please check mark) Never Mild Moderate Severe Depressive mood Memory loss Mental confusion Decreased sex drive/libido Sleep problems Mood changes/irritability Tension Migraine/severe headaches Difficult to climax sexually Bloating Weight gain Breast tenderness Vaginal dryness Hot flashes Night sweats Dry and Wrinkled Skin Hair is Fa lling Out Cold all the time Swelling allover the body Joint pain Other symptoms that concern you: New Fem ale Patient Package Page Number: 5 Revision Date
4 ~ CirapevWne INTeR NAL MEDICINE CENTRE Female Testosterone and/or Estradiol Pellet Insertion Consent Form Nam e:~~ ~=- ~~~ (tnt) IFi!>l) (Middle) Today's Dale: Sio-identical hormone pellets are concentrated hormones, biologically identical 10 the hormones you make in your own body prior to menopause. Estrogen and testosterone were made in your ovaries and adrenal gland prior to menopause. Bic-identical hormones have the same effects on your body as your own estrogen and testosterone did when you were younger, without the monthly fluctuations (ups and downs) of menstrual cycles. Bia-identical hormone pellets are made from yam and are FDA monitored but not approved for female hormonal replacement. The pellet method of hormone replacement has been used in Europe and canada for many years and by select 08/GYNs in the United States. You will have similar ri ~s as you had prior to menopause, from the effects of estrogen and androgens. given as pellets. Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone cannot be given to pregnant women. My birth control method is: (please d rcle) Abstinence Birth control pill Hysterectomy IUD Menopause Tubal ligation Vasectomy Other CONSENT FOR TREATMENT: I consent to the insertion of testosterone and/or estradiol pellets in my hip. I have been informed that t may experience any of the complications to this procedure as described below. These side effects are similar to those related to traditional testosterone and/or estrogen replacement Surgical risks are the same as for any minor medical procedure. Side effects may include: Bleeding. bruising. swelling. Infection and pain; extrusion of pellets; hyper sexuality (overactive libido); lack of effect (from lack of absorption); breast lendernes5 and swelling especially in the first three weeks (estrogen pellets only); increase in hair growth on the face, similar to pre-menopausal patterns; water retention (estrogen only); increased growth of estrogen dependent tumors (endometrial cancer, brent ~an~ erl; sa fely of any of these hormones during pregnancy cannot be guaranteed. Notify your provider if you are pregnant, suspect that you are pregnant or are planning to become pregnant during this therapy. continuous exposure to testosterone during pregnancy may cause genital ambiguity; change in voice (which is reversible); clitoral enlargement (which is reversible). The estradiol dosage that t may receive can aggravate fibrolds or polyps, if they exist. and can cause bleeding. Testosterone therapy may increase one's hemoglobin and hematocrit. or thicken one's blood. This problem can be diagnosed with a blood test. Thus. a complete blood count (Hemoglobin and Hematocrit) should be done at least annually. This condition can be reversed simply by donating blood periodically. BENEFITS OF TESTOSTERONE PELLETS INCLUDE: Increased libido. energy, and sense of well being. Increased muscle mass and strength and stamina. Decreased frequency and severity of migraine headaches. Decrease in mood swings. anxiety and irritability. Decreased weight. Decrease in risk or severity of diabetes. Decreased risk of heart disease. Decreased risk of Alzheimer's and dementia. I ~gree to immediately report to my practitioner's office any adverse reac tion or problems that might be related to my therapy. Potential complications have been explained to me and I agree that I have received information regarding those risks, po tential complications and benefits. and the nature of bio--identical and other treatmen~ and have had all my questions answered. Furthermore. I have not been promised or guaranteed any specific benefits from the administration of bio-identical therapy.! accept tllese ri~s and benefits and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future insertions. I understand that p~yment is due in full at the time of service. I also understand th~t it is my responsibility to submit a claim to my insuranc~ company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy 10 be a covered benefit and my Insurance company may not reimburse me. depending on my coverage. 1 acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my Insurance company or answer letters of appeal. Print Name Signature l eday's Dat~ New Female Patient Package Page Number: 4 Rev'ision Date
5 Grapev,ne ~ INTERNAL MEDICINE CENTRE John S. Ferris, M.D Lancaster Dr. Grapevine, Texas (fax) Dr..lSFeJTis@yahoo.co J1l BioTE Insurance Disclainler Preventative medicine and bio-identical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as Medical Doctors and medical assistants, insurance companies do not recognize it as necessary medicine. It is considered similar to Plastic Surgery (esthetic medicine) and therefore is not covered by health insurance in most cases. As such the insurers do not provide coverage for, nor reimbursement of expenses associated with our services for Bio-Identical Hormonal therapies. This includes consultative fees, laboratory fees, medical procedures such as pellet insertions, and medication expense for the hormonal pellets. Payment is required at the time of service and upon request we will provide a receipt showing the amount paid and the nature of the procedure. This receipt will serve as evidence of your medical expense. We will not call, write, attempt any pre-certification, or contact your insurer regarding this therapy. If we receive inquiry from your insurer we will not respond. Should we receive any funds from your insurer we will return those funds to the sender. 'Patients who have access to a Health Savings Account may pay for treatment related charges with that credit or debit card. By signing this notification, you acknowledge receipt and understanding of this policy. Name: Signature: Date:
INSURANCE DISCLAIMER
INSURANCE DISCLAIMER Preventative medicine and bio- identical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board
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New Patient Information First Name: Last Name: M.I.: Address: City: State: Zip Code: Mobile Phone: Home Phone: Email: Preferred method of communication: Mobile Phone Home Phone Email Date of Birth: Age:
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Have you ever had or are you currently experiencing any of the following? Acne Anorexia Anemia Asthma Bleeding Tendency Blood Disorder Bruising Tendency Cancer-Active Cancer- Remission Cardiac Disorder
Female Hormone Replacement Therapy Packet
200 SW 8 th St, STE A, Ocala, FL 34471 PH: 352-369-0104 FAX: 352-369-0107 Dr. Tad Connine, Medical Director Female Hormone Replacement Therapy Packet Patient Demographics LAST NAME: FIRST NAME: M.1. D.O.B.
IN CASE OF AN EMERGENCY NOT LIVING WITH YOU
GENERAL INFORMATION Name (as it appears on insur card) Address City State Zip Home phone Cell Email Marital status DOB SS# Employer Work # Parent name (if minor) IN CASE OF AN EMERGENCY NOT LIVING WITH
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.