Female Patient Questionnaire & History

Transcription

1 Female Patient Questionnaire & History Name: (Last) (First) (Middle) Today s Date: Date of Birth: Age: Weight: Occupation: Home Address: City: State: Zip: Home Phone: Cell Phone: Work: Address: In Case of Emergency Contact: May we contact you via ? ( ) YES ( ) NO Relationship: Home Phone: Cell Phone: Work: Primary Care Physician s Name: Phone: Address: Address City State Zip Marital Status (check one): ( ) 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 cigars per day. ( ) I drink alcoholic beverages per week. ( ) I drink more than 10 alcoholic beverages a week. ( ) I use caffeine a day. New Female Patient Package Page Number: 1 Revision Date

2 Medical History Any known drug allergies: 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/GYN Exam in the last year. ( ) Mammogram in the last 12 months. ( ) Bone Density in the last 12 months. ( ) Pelvic ultrasound in the last 12 months. High Risk Past Medical/Surgical History: ( ) Breast Cancer. ( ) Uterine Cancer. ( ) Ovarian Cancer. ( ) Hysterectomy with removal of ovaries. ( ) Hysterectomy only. ( ) Oophorectomy( Removal of Ovaries). Birth Control Method: ( ) Menopause. ( ) Hysterectomy. ( ) Tubal Ligation. ( ) Birth Control Pills. ( ) Vasectomy. ( ) Other: Medical Illnesses: ( ) High blood pressure. ( ) Heart bypass. ( ) High cholesterol. ( ) Hypertension. ( ) Heart Disease. ( ) Stroke and/or heart attack. ( ) Blood clot and/or a pulmonary emboli. ( ) Arrhythmia. ( ) Any form of Hepatitis or HIV. ( ) Lupus or other auto immune disease. ( ) Fibromyalgia. ( ) Trouble passing urine or take Flomax or Avodart. ( ) Chronic liver disease (hepatitis, fatty liver, cirrhosis). ( ) Diabetes. ( ) Thyroid disease. ( ) Arthritis. ( ) Depression/anxiety. ( ) Psychiatric Disorder. ( ) Cancer (type): Year: New Female Patient Package Page Number: 2 Revision Date

3 Female Testosterone and/or Estradiol 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 soy 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 is category X (will cause birth defects) and 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 and are included in the list of overall risks below: 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); birth defects in babies exposed to testosterone during their gestation; growth of liver tumors, if already present; 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 & 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 have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above. 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 pellet 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 New Female Patient Package Page Number: 3 Revision Date

4 Name: Date: Symptom (please check mark) Never Mild Moderate Severe Depressive mood Fatigue 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 Falling Out Cold all the time Swelling all over the body Joint pain Family History Heart Disease Diabetes Osteoporosis Alzheimer s Disease Breast Cancer NO YES New Female Patient Package Page Number: 4 Revision Date

5 Hormone Replacement Fee Acknowledgment Most insurance companies do not cover the BioTe hormone replacement therapy. It is considered an elective procedure therefore we do not file a claim to your insurance. You will be responsible for payment at the time of your procedure. The Institute for Hormonal Balance is not liable nor holds any responsibility for reimbursement of claims submitted by the patient for hormone replacement therapy. New Patient Consult Fee (Cash Price) $125 Female Hormone Pellet Insertion Fee $330 Male Hormone Pellet Insertion Fee $625 Male Pellet Insertion Fee ( 2000mg) $725 We accept the following forms of payment: Master Card, Visa, American Express, Personal Check, Discover, and Cash. Print Name Signature Today s Date New Female Patient Package Page Number: 5 Revision Date

6 Cancellation/No Show Policy 1. CANCELLATIONS We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Also the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment schedule. ** If an appointment is not cancelled at least 24 hours in advance you will be charged a fifty dollar ($50) fee. 2. NO SHOWS Patients who do not show up for their appointment and do not call to cancel their appointment will be considered a NO SHOW. Patients who NO SHOW two (2) or more times in a 12 month period, may be dismissed from the practice and they will be denied any future appointments. ** If you are a NO SHOW to your appointment you will be charged a fifty dollar ($50) fee. 3. LATE APPOINTMENTS We understand that delays can happen however we must try to keep the other patients and doctors on If you are 15 minutes or more past your scheduled appointment time you will be asked to reschedule. time. ** The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the patient's next appointment. Please sign that you have understand and agree to the Cancellation and No Show policy. Patient Name (Please print) Signature of Patient or Representative Date New Female Patient Package Page Number: 6 Revision Date

7 HIPPA-Health Insurance Portability and Accountability Act YOUR RIGHTS: Under the federal health Insurance Portability and Accountability Act (HIPPA), you have the right to request restrictions on how we use or disclose your personal information for treatment, payment, or health care operations. You also have the right to request restrictions on disclosures to family members or others involved in your health care or the paying of your care. ACCESS TO YOUR PERSONAL HEALTH INFO: You have the right to inspect and or obtain a copy of your personal health information we maintain in your designated medical records. You must sign a release of medical records consent form to obtain these records. FAMILY, FRIENDS, AND PERSONAL REPRESENTATIVES: With your written consent we may disclose to family members, close personal friends, or another person you identify your personal health information relevant to their involvement with your care or paying for your care. If you are unavailable, incapacitated, or involved in an emergency situation, and we determine that a limited disclosure is in your best physical interest, we may disclose your personal health information without your written consent. We may also disclose your personal health information to the public or private entities to assist in disaster relief efforts. OTHER USES AND DISCLOSURES: We are permitted or required by law to use or disclose your personal health information, without your authorization, in the following circumstances. For public health activities (reporting of disease, injury, birth, death, or suspicion of child abuse, neglect or domestic violence) To government authority if we believe an individual is a victim of abuse, neglect or domestic violence For health oversight activities (for example, audits, inspections, licensure actions or civil, administrative or criminal proceedings or actions) For judicial or administrative proceedings (for example pursuant to a court order, subpoena or discovery request) For law enforcement purposes (i.e. reporting wounds or injuries or for identifying or locating suspects, witnesses or missing persons) To avert a serious threat to health or safety under certain circumstances For military activities if you are a member of the armed forces or an inmate or individual confined to a correctional institution For compliance with worker's compensation claims We will adhere to all state and federal laws or regulations that provide protections to your privacy. We will only disclose AIDS/HIV related info, genetic testing info and info pertaining to your mental condition or any substance abuse problems as permitted by law. Patient Signature Date New Female Patient Package Page Number: 7 Revision Date

8 Permission to Disclose Personal Medical Information Please provide us with the telephone number you would like us to use when contacting you with regards to medical records, such as test results, treatment options, etc. Patient Name: Date of Birth: Primary Phone Number: Secondary Phone Number: Voice Mail Messages: (check one) O Confidential information may not be left on voice mail. O I give permission for the Institute for Hormonal Balance staff members to leave messages, with discretion, on voice mail for the numbers listed above. Disclosure to Other Persons: (check one) O Any information regarding my health record or treatment options may only be discussed with me. O I give permission Institute for Hormonal Balance staff members to disclose health information to the following people: 1. Relationship Phone:, Relationship Phone:, Relationship Phone:, I understand that the release of information may be electronic, written or verbal and that this consent form will remain in effect until a written request for revocation is received by our office. The Institute for Hormonal Balance staff members reserve the right, at our discretion, to limit the disclosure of medical information to additional parties (such as family members) unless we have a signed copy of this form on file. Signature Date New Female Patient Package Page Number: 8 Revision Date