Medical History Questionnaire

Questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Name:
Address:
City:
State:
Zip Code:
Email Address:
Home Number:
Cell Number:
Work Number:
Emergency Contact:
Consultant Name:
Drivers License:
Height:
Weight:
DOB:
Gender:
Marital Status:
Occupation:
Previous or referring doctor:
Date of last physical exam:

Personal Health History

Childhood Illness:

MeaslesMumpsRubellaChickenpoxRheumaticFeverPolioOther
Comments:

List any medical problems that other doctors have diagnosed:

List any past surgeries:

Have you ever had a blood transfusion?
List all of your prescribed drugs:

Allergies to any medications?
If Yes, please explain below:

Health Habits and Personal Safety

All Questions Contained In This Questionnaire Are Optional And Will Be Kept Strictly Confidential.

Do you exercise?
If Yes, how many times per week and what form of exercise:

Diet Are you dieting?
If yes, are you on a physician prescribed medical diet?
Number of meals you eat in an average day?
Rank salt intake
Rank fat intake
List all over the counter supplements:

Caffeine NoneCoffeeTeaColaEnergy Drink
Number of cups/cans per day?
Alcohol Do you drink alcohol?
If Yes, how often?
Tobacco Do you use tobacco?
If Yes, how often?
Drugs Do you currently use recreational or street drugs?
Have you ever given yourself street drugs with a needle?
Sex Are you sexually active?
If yes, are you trying for a pregnancy?
If not trying for a pregnancy list contraceptive or barrier method used:
Any discomfort during intercourse?
Are you HIV/AIDS positive?
Personal Safety Do you live alone?
Do you have frequent falls?
Do you have vision or hearing loss?

Family Health Problems

  Age Significant Health Problems
Father
Mother

Mental Health

Do you feel depressed?
Do you panic when stressed?
Do you have problems with eating or your appetite?
Do you cry frequently?
Have you ever attempted suicide?
Have you ever seriously thought about hurting yourself?
Do you have trouble sleeping?

Women Only

Age at onset of menstruation:
Date of last menstruation:
Period every _____ days
Heavy periods, irregularity, spotting, pain, or discharge?
Number of pregnancies?
Number of live births?
Are you pregnant or breastfeeding?
Have you had a D&C, hysterectomy, or Cesarean?
Any urinary tract, bladder, or kidney infections within the last year?
Any blood in your urine?
Any problems with control of urination?
Any hot flashes or sweating at night?
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?
Experienced any recent breast tenderness, lumps, or nipple discharge?
Date of last pap and rectal exam?

Men Only

Do you usually get up to urinate during the night?
If yes, number of times?
Do you feel pain or burning with urination?
Any blood in your urine?
Do you feel burning discharge from penis?
Has the force of your urination decreased?
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Any difficulty with erection or ejaculation?
Any testicle pain or swelling?
Date of last prostate and rectal exam?

Other Problems

Check if you have, or have had any symptoms in the following areas to a significant degree and briefly explain.

SkinChest/HeartRecent changes in:CirculationHead/NeckBackWeightLungsEarsIntestinalEnergy levelBowelNoseBladderAbility to sleepOther pain/discomfort

Decreased concentration
Increased mood swings
Increased stress levels
Decreased personal drive
Depression
Difficulties sleeping
Decreased energy
Decreased exercise
Decreased muscle strength
Decreased skin elasticity
Decreased libido
Increased wrinkles
Increased fatigue
Nipple sensitivity
Heavy menstrual cycle
Temperature intolerance
Thinning or loss of hair
Sagging or loose skin
Stiff joints in morning
Progressive osteoporosis
Increased back pain
Muscle aches and pains
Endocrine Disorder
Prostate Cancer
Poor wound healing
Decreased sociability
Decreased short term memory
Decreased long term memory
Decreased sense of well being
Feeling less confident
Decreased sex drive
Decreased endurance
Healing from exercise is long
Decreased testicle size
Decreased skin tone
Increased fat deposits
Increased muscle deterioration
Gynocomastia (male breast)
Hot flashes
Painful menstrual cycle
Oral birth control or estrogen
Thinning pubic hair
Thin / dry skin
Decreased bone mass
Increased joint pain
Gastrointestinal bleeding
Joint pain during exercise
Hypertension
Other form of Cancer
Carpal Tunnel Syndrome
Have you experienced problems with your joints? If Yes, explain:
Have you experienced muscle aches and pains? If Yes, explain:
Have you ever been on Hormone Therapy? If Yes, explain:
What is your long term goal?

Patient Authorization and Agreement

In consideration of instructs Hormone Logics providing the submitting patient (“Patient”) with medical management, administrative and referral services, Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement (“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 Hormone Logics or the physicians referred by Hormone Logics could result in inappropriate treatment. Patient authorizes and Hormone Logics to obtain on my behalf medical laboratories, diagnostic testing, physicians and dispensing pharmacies. In addition, Patient authorizes and instructs Hormone Logics and physicians referred by Hormone Logics (“Physicians”) 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 Hormone Logics under this Agreement. Patient agrees to present photo identification upon any blood testing pursuant to a Hormone Logics or Physician test requisition. Patient acknowledges that therapies and laboratory and diagnostic testing services supplied or obtained by Hormone Logics, and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance.



Patient acknowledges that Hormone Logics’s employees and advisors are no licensed physicians and that Physicians obtained on my behalf by Hormone Logics are independent contractors, which will be compensated by Patient with funds provided to Hormone Logics. I further understand and agree that Hormone Logics and Physicians are rendering the medical care, services and treatment and that Hormone Logics 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 Hormone Logics and Physician with written notice of any such adverse reaction or side effect. I further acknowledge and agree that Hormone Logics 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 Hormone Logics 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 Patient’s hormone replacement therapy, as prescribed by Physician, may be the highest level of standard reference range for Patient’s 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 Patient’s physical condition and health. Patient further acknowledges that the methods of medical treatment offered by Hormone Logics and Physician are not accompanied by claims, guarantees, promises or warranties. In compliance with federal and state laws, there will be no refund given for any medication purchased from Hormone Logics.



Patient is freely seeking medical consultation via the internet and acknowledges and consents to Physician reviewing Patient’s medical history without the opportunity to conduct an in-person physical examination. Patient solicits Hormone Logics 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 Patient’s state or country of residence. Further, Patient agrees that Physician’s consultations, diagnosis, 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 the Physician will not rely or substitute the advice of Physician should it conflict with the advice given to me by Patient’s 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.



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 the 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 server able.

Patient covenants and agrees to indemnity, defend, protect and hold harmless Hormone Logics and Physician and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (“Indemnified Parties”) from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demand, 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, Hormone Logics and/or Physician’s rendering medical care, services, advice and/or treatment.

Patient’s failure to disclose all relevant information regarding Patient’s medical and physical condition, acts or omissions of Hormone Logics or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Hormone Logics 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 Indemnifications Parties there from.

I HAVE READ AND UNDERSTAND THE PATIENT AUTHORIZATION AND AGREEMENT

Patient Printed Name:
Last 4 of SSN: