LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
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1 LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: ADDRESS: MARITAL STATUS: ( ) SINGLE ( ) MARRIED ( ) DIVORCED ( ) WIDOWED ( ) SEPERATED ( ) UNDISCLOSED PATIENTS EMPLOYER: WORK #: BUSINESS ADDRESS: CITY: STATE: ZIP: SPOUSE OR PARENTS NAME: EMPLOYER: WORK #: EMERGENCY CONTACT: PHONE: WHOM MAY WE THANK FOR REFERRING YOU: _ NAME OF PERSON RESPONSIBLE FOR ACCOUNT: RELATIONSHIP TO PATIENT: DATE OF BIRTH: DRIVER'S LICENSE #: _ STATE: ADDRESS: CONTACT #: ( ) CELL ( ) HOME PATIENT SIGNATURE: DATE:
2 Health History Questionnaire: Patient Name: DOB: Date: Occupation: _ Primary Care Doctor (PCP): Phone number: Pharmacy Number: Date of last physical exam: Personal Health History Please circle all that apply: General Diabetes High Cholesterol Unwanted Weight Loss Cancer Personal History of Cancer Family History of Cancer Cardiovascular Heart Failure Chest Pain Heart Murmur Vascular Disease Blood Clots Edema Hypertension Respiratory Sleep Apnea Shortness of breath Asthma Bronchitis Pneumonia Allergies Gastrointestinal Lactose Intolerance Gall Bladder Gall Stones Chronic Diarrhea Chronic Constipation Genitourinary Prostate Cancer Prostate Cancer Family Overactive Bladder Painful Urination Decreased urinary force On/Off Urine Flow Enlarged Prostate (BPH) Blood in Urine Kidney/Bladder History Infection Kidney Bladder Liver Any Other Psychiatric History of Depression Personality Disorder Any Other List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers. Please make sure to include any anti-anxiety or anti-depressant medications. Taken for Taken for Taken for Taken for
3 Allergies: No Known Allergies Or List Allergies and Reaction Surgeries: Year Surgery/Reason Year Surgery/Reason HEALTH HABITS AND PERSONAL SAFETY Exercise: Sedentary (No exercise) Mild exercise Occasional vigorous exercise Regular vigorous exercise Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week) Have you used Testosterone (prescribed or otherwise) or any other anabolic steroids in the past? Please be completely truthful with your response, it is critical in order to diagnose and prescribe correctly. Rate your quality of sleep: 1-Worst 10-Best Lifestyle Questionnaire Alcohol: Yes Number of drinks per week: Tobacco: Yes Cigarettes Cigars Chewing How many/much: Illicit drug use: Yes Explain No No No Vitals Blood Pressure Respiratory Rate Weight
4 SYMPTOMS OF LOW TESTOSTERONE LEVELS Decreased concentration Yes No Difficulty learning new things Yes No Memory loss Yes No Moodiness Yes No Depression Yes No Increasing fatigue Yes No Decreasing energy Yes No Daytime sleepiness Yes No Poor sleep habits Yes No Erectile dysfunction Yes No I have had testosterone checked previously Yes No I have used testosterone previously Yes No If yes, date(s): Type: Usage: Patient Name (Print) DOB: Signature: Date:
5 ACH Debit Authorization Form I _ not to exceed the amount shown. Authorize Low T Nation to charge my credit card for services rendered AMOUNT $ USD Monthly ACH Acct Routiing # CREDIT CARD ( $10 Additional Fee) CARD NUMBER CARD CVC EXPIRATION DATE BILLING ADDRESS BILLING ZIP CODE NAME ON CARD (As it appears on card) SIGNATURE DATE
6 Consent for Testosterone Replacement/ hcg Therapy/ No Other Therapy Agreement Patient Name: DOB: A FEW THINGS TO KNOW ABOUT TESTOSTERONE REPLACEMENT/hCG THERAPY (TRT) It is important to understand that all medicine is an inexact science. Although we will carry out your treatment carefully, results may vary in their degree of success. It is quite natural for a patient undergoing Testosterone Replacement Therapy to want to know that everything will turn out all right. While most of the time this is the case, it is very important for you to be aware of the potential risks, as well as the benefits, expected from the treatment when deciding on whether to begin Testosterone Replacement Therapy. You should also be aware of the alternatives to Testosterone Replacement Therapy, including not receiving the treatment. It is important that you consider the information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take some time to weight your options or consult another health care provider. Please review the following statements, which discuss informed consent. Any questions that you may have should be brought to our attention. Your clinical provider will attempt to answer all your questions to your satisfaction. Directions: Initial beside each statement that you have read, understand and agree with. 1. This is my consent LOW T NATION, LLC., including any physician or nurse who works with the company, to begin my treatment for Testosterone Replacement Therapy. 2. It has been explained to me, and I fully understand, that occasionally there are complications with this treatment such as Acne, Breast Enlargement, Mood Swings, as well as the following (#3-#7) 3. Extra fluid in the body- This can cause problems for patients with heart, kidney or liver disease. 4. Sleep disturbance - This is called sleep apnea and is more likely to occur with patients who have lung disease or are overweight. 5. Prostate enlargement- this may cause problems with urinating. 6. Changes in cholesterol levels, red blood cell levels, PSA levels, liver function enzymes, and other hormone levels which will be monitored with periodic blood tests. 7. I understand that I will have periodic blood tests to monitor my blood levels. 8. I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse. 9. I have had an opportunity to discuss with LOW T NATION, LLC. and its medical practitioners my complete past medical and health history including any serious problems and/or injuries. All of my questions concerning the risks, benefits and alternatives have been answered. I am satisfied with the answers.
7 10. I understand that the physical exam by LOW T NATION, LLC. does NOT replace a full physical exam by a personal physician. 11. I agree to have my personal physician perform a yearly full physical exam including a digital rectal exam, lipid profile, cholesterol levels and a comprehensive metabolic panel. If I do not have a personal physician, LOW T NATION, LLC. will assist in locating one for me. 12. Family Planning for the patient has been discussed. 13. I understand that prolonged TRT therapy may reduce ejaculate volume and reduce sperm count, possibly affecting fertility. 14. I have been trained on how to administer intramuscular and subcutaneous injections from a licensed medical practitioner who is approved to perform such tasks. I,, agree that, while a patient of LOW T NATION, LLC., I will not take any type of anabolic steroids, testosterone gels, hormone boosters, pro-hormones or any additional testosterone supplementation not provided by LOW T NATION, LLC. during my treatment plan. At any time, if use of these items is discovered, I understand I will be discharged as a patient of LOW T NATION, LLC.. Patient Signature Date Witness Signature Date
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Linda Lea, APRN-CNP, PLLC 4771 NW 122 nd Street, Suite C Oklahoma City, Oklahoma, 73120 Office: 405-607-6770 Fax: 405-607-6774
4771 NW 122 nd Street, Suite C FEMALE NEW PATIENT PELLET PACKET Please carefully read and complete the contents of this package so we can be ready for your appointment to regain optimal hormone balance.
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable
Integrated Medical Services (IMS) New Patient Registration Sheet
Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics
Douglas G. Benting, DDS, MS, PLLC Practice Limited to Prosthodontics Patient s Name Birthdate Who referred you to this office? Social Security # Address City ST ZIP Home Phone Work Phone Ext Cell Phone
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax