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Medical History Form

Therapies cannot be provided unless your physical exam, medical history, and lab work show a clinical need. Completing the required forms, lab work and exams doesn’t automatically qualify you for treatment. Only the prescribing physician can determine if you qualify.

Required Information

Please select your counselor's name or choose "New Patient."

How did you hear about us?

Full Name (required):
Street Address (required):
City (required):
State (required):
Zip Code (required):

Contact Information

Your Email (required):
Phone Number (required):

Personal Information

Birth date:
Sex:  Male Female
Height:
Weight:
Occupation:

What are your primary goals/desires/expectations from your treatment at HHWPB?

Current Symptoms

Do you have or have you ever had any of the following? (Mark all that apply)
 Cold or heat intolerance Decreased memory Increased wrinkles Muscle loss Decreased sex drive Decreased desire or ability to exercise Difficulty sleeping Hot flashes/flushes Lack of drive Progressive Osteoporosis (decreased bone mass or stooped posture) Sagging muscles or breasts Increased body fat Mood swings Loss of concentration Decreased energy Decreased endurance Decreased sense of well being Decreased muscle strength Decreased testicle size Loose or thin skin

Specific Female Patient Questions

 Vaginal dryness Weight gain Weight loss Decreased Libido Hair Loss / Thinning Irregular periods PMS Experiencing menopause

Date Last Period Ended:

Medications

Please list ALL medications by name and dosage (including supplements):

Drug Allergies

Please list name of drug and your reaction to it.

Past Medical History

Please list hospitalizations, operations and any other significant illness with dates.

Family Medical History

Are there any of the following in the family? If any answers are checked “Yes”, please explain.
 Cardiovascular disease Diabetes Hypertension Lipid disorder Breast cancer Prostate cancer Other cancers Other illness

Please detail ANY of the above, including which family members were affected:

Social History

Do you smoke?  Yes No
If "yes", how many cigarettes and/or packs per day?

Do you drink?  Yes No
If "yes", how many drinks per week?

Do you exercise?  Yes No
If "yes", how often?

Are you a professional athlete?  Yes No
Are you a former professional athlete?  Yes No
Are you an Olympic athlete?  Yes No
Are you a former Olympic athlete?  Yes No
Do you check labels for trans fat?  Yes No
Do you avoid sugar?  Yes No
Do you avoid processed foods?  Yes No
Do you consume water daily?  Yes No

Sleep

How many hours do you sleep at night?

Lights completely off?  Yes No
Is it hard for you to fall asleep?  Yes No
Do you wake up early or multiple times?  Yes No
Are you refreshed upon waking up?  Yes No

Hormonal

Would you like improvement of libido?  Yes No
If male, would you like improvement of erection?  Yes No
If female, would you like improvement of lubrication?  Yes No

Metabolic

Do you feel good about your body image and weight?  Yes No
I usually feel  Cold Hot Just Right Other
If "Other", how?

On a scale of 1-10, which energy level describes you best, most of the time?

Head Trauma

Any history of car accident, head trauma (even mild jarring), etc?  Yes No

Mood

I usually feel:  Flat Anxious Depressed Irritable Foggy Other

If "Other", please explain:

Patient History

Do you have or have you ever had any of the following? If "yes" explain in area below.

 Any known deficiencies including minerals and electrolytes Blood disorders History of cancer Carpel tunnel syndrome Chemical dependency Drug allergies Edema or excess fluid retention Emotional disorders or depression Genital or urinary disorders Glaucoma Heart disease or heart attack Hyperlipidemia or high cholesterol Hypertension or high blood pressure Immune disorders Lactating Lung disorders Neurological disorders - thyroid, diabetes or other Endocrinological disorders including insulin resistance Orthopedic or muscle disorders - fracture or joint disorders Poor wound healing Renal or kidney disease Upper respiratory problems

Please explain:

Disclaimer: Please read before submitting the form below!

In consideration of Hormone Health and Wellness of the Palm Beaches providing the undersigned patient with medical management, administrative and referral services, Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement. With this Agreement, Patient submits with this Agreement an accurately completed Medical History Form (MHF). Patient agrees to respond to truthfully, accurately and completely in completing the MHF and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to HHW or the physicians referred by HHW could result in inappropriate treatment.

Patient authorizes and HHW to obtain on my behalf medical laboratories, diagnostic testing, physicians and dispensing pharmacies. In addition, Patient authorizes and instructs HHW and physicians referred by HHW and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the MHF, laboratory diagnostic tests, and other information submitted to HHW under this Agreement. Patient agrees to present photo identification upon any blood testing pursuant to a HHW or Physician test requisition. Patient acknowledges that therapies and laboratory and diagnostic testing services supplied or obtained by HHW, and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance.

Patient acknowledges that HHW employees and agents are not licensed physicians and that Physicians obtained on my behalf by HHW are independent contractors, which will be compensated by Patient with funds provided to HHW. Patient acknowledges that HHW does not practice medicine and that HHW is a medical management, administration and referral service and does not direct, control or influence the treatment decisions made by Physician. Patient further understands and agrees that HHW and Physicians are rendering the medical care, services and treatment and that HHW is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by any pharmacy in my country of residence. Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by Physician, to immediately cease any medical treatment prescribed by Physician in the event of any adverse reaction or side effect arising from prescribed treatment, and to immediately provide HHW and Physician with written notice via fax to HHW of any such adverse reaction or side affect. I further acknowledge and agree that HHW is not liable for any negligent act or omission of the Physician.

Patient acknowledges that diagnosis and treatment may involve risk of injury, and that HHW and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing, analysis of test results, examination of medical history or hormone treatment. Patient acknowledges that the hormone blood level objective sought as a result of Patients hormone replacement therapy, as prescribed by Physician, may be at the highest level of a standard reference range for Patients age and sex, or, in some cases, above such range, to the level of a younger person, and that such range is experimental and may not render any benefits, but may result in unknown, adverse results. Patient is aware of the nature, risk and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone replacement treatment. Patient acknowledges that recombinant human growth hormone replacement therapy involves the use of a medical drug approved for one purpose for a new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone replacement therapy for the purpose of authorizing Physician to administer such treatment to relieve body ailments and attempt to enhance Patients physical condition and health. Patient further acknowledges that the methods of medical treatment offered by HHW and Physician are not accompanied by any claims, guarantees, promises or warranties.

Patient is freely seeking medical consultation via the Internet and acknowledges and consents to Physician reviewing Patient's medical history without having the opportunity to conduct an in-person physical examination. Patient solicits HHW for a specific prescription medication to treat an already-identified medical or cosmetic condition. Patient acknowledges that Physician may not be licensed to practice medicine in Patients state or country of residence. Further, Patient agrees that Physicians consultations, diagnoses, and treatments will be deemed to have occurred in Florida, where physician is licensed to practice medicine.

Patient represents that he or she is under the care of a primary care physician and that Physician will not rely or substitute the advice of Physician should it conflict with the advice given to me by Patients primary care physician. Before taking any medication prescribed by Physician, Patient agrees to have a comprehensive physical examination by his or her primary care physician. Patient agrees to notify his or her primary care physician and advise such physician that Patient is undergoing hormone replacement therapy.

Patient acknowledges that under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. PHYSICIAN HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.

Patient acknowledges and agrees that HHW is not responsible for the negligent or intentional acts or omissions of any health care provider or supplier that Patient is referred or for any action or inaction taken by Patient, that the total liability of HHW, its officers, directors, employees, agents and stockholders is limited to the purchase price of any products through HHW, Physicians or pharmacies, and that HHW and Physicians will not be liable for any direct, indirect, special, incidental, consequential, or punitive damages. During Patients relationship with HHW and Physician, HHW and Physician will convey to Patient a range of proprietary business information, including, confidential disclosures and trade secrets business practices and HHW customers and suppliers. No matter how received by Patient during the parties relationship, Patient agrees that Confidential Information is confidential, proprietary and uniquely valuable to HHW and gravely affects the conduct of business of HHW and HHW goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any of Confidential Information or take any action that may result in disclosure of Confidential Information to any third-party person, firm, or business. Patient agrees that if the terms of this paragraph are breached, HHW shall be conclusively deemed to be irreparably injured and shall be entitled to an injunction restraining Patient from disclosing any of the Confidential Information and to liquidated damages. Patient agrees that the amount of HHW actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such liquidated damages are not a penalty.

Based on the above-understanding, Patient agrees to release HHW, its officers, directors, employees, agents and shareholders, and Physician from any and all liability associated with or arising from the Physicians consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physicians consultation.

This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Palm Beach County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.

This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void and of no effect.

If any provision of this Agreement or the application thereof to any person or circumstances is held invalid or unenforceable in any jurisdiction, the remainder hereof, and the application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable.

Patient covenants and agrees to indemnify, defend, protect and hold harmless HHW and Physician and their respective officers, directors, employees, stockholders, assigns, successors and affiliates from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paid by the Indemnified Parties in connection with, resulting from or arising out of, directly or indirectly, HHW and/or Physicians rendering medical care, services, advice, and/or treatment, Patients failure to disclose all relevant information regarding Patients medical and physical condition, acts or omissions of HHW or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by HHW or Physician. Patient is aware of potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties there from.

 I attest that I am here for age management services
 I attest that I am not a professional athlete
 I attest that I am not looking for body enhancement
 I attest that I am not looking for aesthetic enhancement

I have completed the medical history form to the best of my knowledge. I certify that my answers are complete, honest and true.

Signed: Date:

Disclaimer

IMPORTANT! All information presented in this website is intended for informational purposes only and not for the purpose of rendering medical advice.

Therapies cannot be provided unless your physical exam, medical history, and lab work show a clinical need. Completing the required forms, lab work and exams doesn't automatically qualify you for treatment. Only the prescribing physician can determine if you qualify.