Hormone Self-Assessment Weigh Less, Live Longer: Quality Innovation Experience Since 2007
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1 Page 1 of 7 1/2019 (web) Consulting Practitioner: Consultation Date: How did you hear about Thrive Bio-Identical Hormone Replacement Treatments? Advertisement Another Patient Healthcare Provider Books/Articles Website Other (please specify) Personal Information Patient Name: Address: Date: DOB City: State: Zip: Phone: Fax: Do you understand what Biologically Identical Hormone Replacement is? Do you understand the risks associated with the use of Biologically Identical Hormone Replacement? *It is recommended that you consult with your physician regarding these risks. What are your goals for Biologically Identical Hormone Replacement? Medical History Family History Cancer (type) Heart Disease Diabetes High Blood Pressure Osteoporosis Other (relationship)
2 Page 2 of 10 1/2018 Medical History (Cont) Personal History Blood Clots Fibrocystic Breasts Ovarian Cysts Uterine Fibroids Abnormal Vaginal Bleeding PCOS Smoking History Stroke Other Impaired Liver Function Thrombophlebitis Other Endometriosis Cancer (type) Heart Disease Diabetes High Blood Pressure Osteoporosis Cholesterol Serum: Date: Triglycerides: HDL: LDL: Chol/HDL Ratio: Bone density scan results: Date: Current Health Care Provider/s: Difficulty Concentrating Can t Sleep (Insomnia) Depressed or Unhappy Anxious Headaches Moodiness/Emotional Swings Painful or Swollen Breasts Weight gain/ Bloating PMS To what degree do you experience the following? None Slightly Moderate Severe Extreme Night Sweats None Slightly Moderate Severe Extreme Difficulty Remembering Things Brain Fog/ Burned out Feeling Hot Flashes Vaginal Dryness Dry Hair/Skin Incontinence Frequent Urinary Tract Infections Inability to Reach Orgasm Painful Intercourse Lack of Sexual Desire Fatigue/Loss of Energy
3 Page 3 of 7 General Health & Lifestyle General Health: Good Fair Poor Height: Weight: Do you exercise, describe: Menstrual Cycle: None Regular Date of last period: Irregular / Explain (heavy, how long,etc): Surgery: Oophorectomy Hysterectomy Tubal Ligation Other None Date of Surgery: (ovaries) (uterus) Current Medications & Reason: Current Vitamins / Minerals / Herbal Formulas: Prior Hormone Replacement Therapy History: (include dates of use) Known Allergies (drug, food, pollen): Are you currently following a special diet (Gluten Free, Casien Free, Arkins, Paleo, etc): Do you eat/drink soy: Caffeine/amount per day: Alcohol/amount per day: Notes and/or Questions:
4 Page 4 of 7 BHRT Considerations BHRT Dosage Form: Would you prefer your treatment using a Prescription filled using a: Sub-dermal Pellet Administered once every 3-4 Months (Women) or 4-6 Months (Men) Topical gel applied once daily to inner arms or Thighs. Sublingual tablets dissolved under the tongue twice daily. Baseline hormone levels must be checked. This can be achieved by testing blood within the Thrive Health and Wellness clinic location or at a LabCorp or Quest Diagnostics lab center. We test for the following hormones: Women (For overall health check a,b, and c yearly.) a. Pap Smear b. Thyroid: TSH, T3, and T4 c.cortisol d. Testosterone (Free & Total) e. Progesterone f. Estradiol, and Estrone g. DHEA (Sulfate) h. Vitamin D3 (25 Hydroxy) Optional: Reverse T3 (practitioner discretion) If you have recently (within 1-2 months) had a blood hormone test (including all of the above items), please bring them along with your questionnaire to your scheduled consultation within the clinic at Thrive. Where to go from here: I would like a consultation and recommendation from a Thrive Health Solutions Practitioner. ü Please Call Thrive Health Solutions at (303) to schedule a consultation. I will bring this completed questionnaire to my appointment. I will contact my practitioner about further lab testing. Notes and/or Questions:
5 Page 5 of 7 Waiver I hereby release Thrive Health and Wellness, LLC, all its employees, associates and pharmacists from any and all liability whatsoever associated with or connected with my Biologically Identical Hormone Replacement Therapy (BHRT), consultation and/or use of BHRT. I acknowledge that I am legally responsible for and aware of the potential side-effects associated with BHRT. I understand that no doctor, practitioner, nurse, pharmacist, or administrative personnel can guarantee that BHRT will provide the results I seek. I am participating in this program by my own choice, and assume all responsibility for my use of BHRT. I fully understand that it is my responsibility to have an annual physical examination along with appropriate laboratory testing. I am currently under the medical supervision of a primary care physician. I have been advised in this hormone self-assessment about the increased risks of heart disease, myocardial infarction, stroke, and breast cancer possibly associated with the use of BHRT. I have answered truthfully all of the questions on this questionnaire. Signed Date Privacy Agreement Starting April 14, 2003, healthcare providers must comply with a new set of federal regulations. The regulations are part of the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), which addresses your rights to privacy and handling of Protected Health Information ( PHI ). Respect for your privacy is a top priority at Thrive Health and Wellness, LLC. Concern for your privacy rights goes hand in hand with our focus on maintaining and improving your health. One of the regulations requires that all of our patients receive our Notice of Privacy Practices at the time of, or prior to, our providing healthcare services. We are also required to ask each patient to sign an acknowledgment indicating receipt of this notice. In an effort to ensure that there will not be a delay in your first treatment from Thrive Health and Wellness, LLC, and that you are provided with prompt service, we ask that you read and sign the Notice of Privacy Practices Acknowledgment form at the bottom of the page and return to us. For Privacy Agreement Questions, please contact the clinic at: Thrive Health and Wellness, LLC 88 Inverness Circle E, Bldg A, Ste 204 Englewood, CO Fax: (303) info@thrivecolorado.com ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Patient Last Name Patient First Name M.I. Street Address City State Zip ( ) Telephone Number My signature below certifies and acknowledges that I have read and understand Thrive Health and Wellness s Notice of Privacy Practices. Patient Signature (or authorized representative) Date
6 Page 6 of 7 Female Testosterone/Estradiol and/or BHRT Pellet Insertion Consent Form Name: Today s Date: (Last) (First) (Middle) Bio-identical hormone pellets are concentrated hormones, biologically identical to 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. Bio-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. Bio-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 OB/GYNs in the United States. You will have similar risks 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 circle) 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 I 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 tenderness 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, breast cancer); safety 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 I may receive can aggravate fibroids 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 agree to immediately report to my practitioner s office any adverse reaction 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, potential complications and benefits, and the nature of bio-identical and other treatments 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. I accept these risks 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 payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage. I 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 Today s Date
7 Page 7 of 7 Hormone Replacement Fee Acknowledgment 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 RN s or NP s, insurance does not recognize it as necessary medicine BUT is considered like plastic surgery (aesthetic medicine) and therefore is not covered by health insurance in most cases. This practice is NOT associated with any insurance companies, which means they are not obligated to pay for our services (blood work, consultations, insertions or pellets). We require payment at time of service. We WILL NOT, communicate in any way with insurance companies. The form and receipt are your responsibility and serve as evidence of your treatment. We will not call, write, precertify, or make any contact with your insurance company. Any follow up letters from your insurance to us will be disregarded. If we receive a check from your insurance company, we will not cash it, but instead return it to the sender. Likewise, we will not mail it to you. For patients who have access to a Health Savings Account, you may pay for your treatment with that credit or debit card. This is the best idea for those patients who have an HAS/FSA as an option in their medical coverage. New Patient Consult Fee. $ (may be waived) Blood Hormone Panel Testing $49* to $149* ea. Female Hormone Pellet Insertion Fee (includes testosterone pellets). $499^ We accept the following forms of payment: Master Card, Visa, Discover, American Express, Personal Checks and Cash. **We also offer interest-free in-house Payment Plans** Print Name Signature Today s Date
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Page 1 of 5 12/2016 Consulting Pharmacist: _Consultation Date: How did you hear about College Pharmacy s & Consultation Services? Advertisement Another Patient Healthcare Provider Books/Articles Website
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Estrogen Self Test Check yes if you experience the associated low estrogen symptom. Are you experiencing hot flashes? Do you feel exhausted on a daily basis? Do you suffer from headaches/migraines? Do
Apples & Oranges Synthetic vs. Bio-Identical Studied Under the Nation s Greats in Hormone Therapy! Salt Lake City Dr. Neal Rouzier Orlando Dr. Sangeeta Pati Naples Dr. Daved Rosensweet And finally Dallas
Patient Health Forms
Patient Health Forms All forms MUST be completed and signed prior to seeing the Provider First: M: Last: Email Address: Home Address: Best Phone Number to Reach You: Last 4 of your social security #: Marital
Female Patient Intake Form
Basic Information STREET ADDRESS CITY, STATE, ZIP HOME PHONE ALTERNATE PHONE EMAIL ADDRESS HOW DO YOU PREFER TO BE CONTACTED? EMAIL PHONE BIRTH MARITAL STATUS SINGLE MARRIED WIDOWED DIVORCED REFERRED BY
Patient Information Form
Patient Information Form Welcome to West Cancer Center We want to provide excellent service. The following information will allow us to accurately handle your billing and insurance. First Date Referring
University Gynecologic Oncology Associates
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Pre-Post Reproductive years, The Change. Nayan Patel PharmD
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Hormone Replacement Therapy For Women
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ANTI-AGING HORMONE BALANCING WEIGHT LOSS NUTRITION
We take your symptoms and an evaluation of your entire endocrine system to determine how to treat you, as an individual. Please take the time to fill out the following forms and questionnaires before your
Progesterone. What is progesterone? Important information. Before taking this medicine
Progesterone Generic Name: progesterone (proe JESS te rone) Brand Names: First Progesterone MC10, Menopause Formula Progesterone, Prometrium What is progesterone? Progesterone is a female hormone important
Accession #: Patient: Jane Doe Convert to pdf, Save or PRINT >> ADRENAL CHECK
Page 1 of 5 Patient: Jane Doe Tel: (123) 456-7890 Email: test@test.com Sex: Female Age: 36 yr Date of Birth: 1980-12-12 Height: 5 ft 0 in Weight: 135 lbs Waist size: 30 in 1st day of last menses: Day 07,
NEW PATIENT HEALTH AND MEDICAL SURVEY
NEW PATIENT HEALTH AND MEDICAL SURVEY Welcome to our practice. As a new patient, please answer the questions below to the best of your ability. Date Patient Name Birth Date Home Phone Work or Cell Phone
Multi-Diagnostic Services, Inc.
Multi-Diagnostic Services, Inc. 139-16 91st Avenue Jamaica, New York 11435 718 454-8556 Fax: 718 454-7950 Name: Date of Appointment: AM Time: PM What to Expect and How to Prepare for the Mammography Screening
Tricia Fox Phone:
Wellspring Functional Health and Nutrition 301 East Carmel Drive, Suite 100-C Carmel, IN 46032 Tricia Fox wellspringfunctionalhealth@gmail.com Phone: 317-750-6121 GENERAL INFORMATION Name Preferred Name
Medications/Supplements/Vitamins/Herbs currently taking regularly
Consultation Evaluation Name Date of birth E-mail address Phone # What is the main issue that brought you here? Primary Physician Health Insurance HMO?PPO? Last Paps Last Blood Tests Last Mammogram Social
Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other
Welcome! Please complete this new client paperwork and return to us at least 48 hours prior to your appointment. This will allow our medical team to review your case in advance of your arrival. If you
Test Results SB Samples Arrived: 01/15/2014 Samples Collected: Saliva: 01/11/14 07:14 Date Closed: 01/18/2014
Test Results 8605 SW Creekside Place Beaverton, OR 97008 Phone: 503-466-2445 Fax: 503-466-1636 info@zrtlab.com www.zrtlab.com 2014 01 15 001 SB Samples Arrived: 01/15/2014 Samples Collected: Saliva: 01/11/14
New Patient Information
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: