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Do you take any blood thinning products such as Vitamin E, Plavix, Coumadin, or Aspirin?
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Please Explain Below
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Do you smoke? (cigarette, pipe, marijuana, chew, etc.)
NO and Never have
YE
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Type of Smoking? (cigarette, pipe, marijuana, chew, etc.)
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Please describe and family health issues below:
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Other Hereditary Illness - Unknown
Mother Illnesses/Reason For Death
Father Illnesses/Reason For Death
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HEALTH HISTORY FORM 2
Do you have or have you everr had any of the following:
CONSTITUTIOINAL
Fever or Chills
No
Yes
Chills Explain
Weight loss
No
Yes
Weight loss Explain
HEMATOLOGIC
Hepatitis
No
Yes
Hepatitis Explain
HIV/Other Blood Diseases
No
Yes
HIV/Other Blood Diseases Explain
Bleeding Disorders
No
Yes
Bleeding Disorders Explain
ENDOCRINE
Thyroid Problems
No
Yes
Thyroid Problems Explain
Diabetes
No
Yes
Diabetes Explain
MUSCULOSKELETAL
Arthritis
No
Yes
Arthritis Explain
Mobility/Joint Problems
No
Yes
Mobility/Joint Problems Explain
GASTROINTESTINAL
Constipation
No
Yes
Constipation Explain
Diarrhea
No
Yes
Diarrhea Explain
Blood in Stool
No
Yes
Blood in Stool Explain
Nausea/Vomiting
No
Yes
Nausea/Vomiting Explain
Liver Problems
No
Yes
Liver Problems Explain
CARDIOVASCULAR
Heart Problems
No
Yes
Heart Problems Explain
Deep Vein Thrombosis/DVT
No
Yes
Deep Vein Thrombosis/DVT Explain
Blood Clots in Lungs/Legs
No
Yes
Blood Clots in Lungs/Legs Explain
High Blood Pressure
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Yes
High Blood Pressure Explain
RESPIRATORY
Asthma
No
Yes
Asthma Explain
Sleep Apnea
No
Yes
Sleep Apnea Explain
SKIN
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No
Yes
Breast Abnormalities Explain
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Yes
Nipple Discharge Explain
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Yes
Changes in Moles Explain
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Yes
Lesions Explain
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Yes
Rashes Explain
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Yes
History of Keloids Explain
NEUROLOGICAL
Neurological Problems
No
Yes
Neurological Problems Explain
Headaches
No
Yes
Headaches Explain
GENITOURINARY
Genital or Oral Herpes
No
Yes
Genital or Oral Herpes Explain
S.T.D.'s
No
Yes
S.T.D.'s Explain
Blood in Urine
No
Yes
Blood in Urine Explain
Urinary Tract Infection
No
Yes
Urinary Tract Infection Explain
Problems Urinating
No
Yes
Problems Urinating Explain
Prostate Problems
No
Yes
Prostate Problems Explain
Kidney Problems
No
Yes
Kidney Problems Explain
EYES
Vision Problems
No
Yes
Vision Problems Explain
ENT
Hearing Problems
No
Yes
Hearing Problems Explain
Sinus Problems
No
Yes
Sinus Problems Explain
PSYCHIATRIC
Mood Swings
No
Yes
Mood Swings Explain
Anxiety/Depression
No
Yes
Anxiety/Depression Explain
Other Conditions / Illnesses
Please list any other conditions/Illnesses not indicated above.
To the best of my knowledge, this information is complete and correct. I understand that it is my responsibility to inform my doctor if there are any changes to my health.
Enter Full Name
Date
MM slash DD slash YYYY
Consent For Treatment
My initials below is to certify I have read this consent. I understand I will receive oral explanation of my treatment plan by Dr. Dennis Courtney. If I consent to the treatment plan described to me by Dr. Courtney and his staff, I understand and accept that additional costs may be incurred by me and I am solely responsible for these expenses. I understand that I may ask further questions at any time. I understand I may stop treatment at any time. Please initial below to acknowledge this agreement.
Patient Initials
Date
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HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patients rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. By signing this form, I understand that:
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent
May we phone, email, or send a text to you to confirm your appointment
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May we leave a message on your answering machine at home or on your cell phone?
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May we discuss your medical conditions with any member of your family?
Yes
No
If YES, please name the members allowed:
This consent was performed by:
PLEASE PRINT NAME
Date
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Medical Treatment Agreement
This Agreement Between
First
Last
and ReGenesis HRT, LLC. establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA “controlled or “scheduled” medications. ReGenesis HRT and Patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and therefore, these agents are prescribed with caution.
THE PATIENT ACCEPTS AND AGREES TO THE FOLLOWING CONDITIONS:
I understand that the medical treatment offered by ReGenesis HRT and their Physician(s) is not accompanied by any claims, guarantees, promises or warranties.
I understand that the medicaions I have purchased are prescribed for me based on diagnoses derived from my submitted medical history, blood/lab work, and physical examination. They are to be used exclusively for treatment of these diagnoses.
I will not attempt to obtain “scheduled” hormone replacement therapy medications illegally or from any other healthcare practitioner without disclosing my current medication usage. I understand that it’s against the law to do so.
I will immediately report any adverse side effects related to the use of my medications to ReGenesis HRT and discontinue use until advised to resume usage by ReGenesis HRT.
I understand that the ReGenesis HRT Physician (MD) and/or Licensed Physician’s Assistant (PA-C) are available for questions and/or concerns during normal business hours throughout the course of my treatment.
I will safeguard my medications from loss or theft and will be responsible for their safekeeping.
I agree that these medications are for my personal use only and no other purpose and I will not share, sell, or trade my medications.
I agree that I will use my medications at the prescribed rate and dosage and will keep the medication in its respective labeled container.
I agree and understand that federal regulations prohibit the return of prescribed medications.
I agree to contact ReGenesis HRT 4-6 weeks into the start of my therapy (and every 3 months thereafter) to arrange for any follow-up blood testing and/or an office visit/consultation as required by the ReGenesis HRT physician.
I agree and understand that I am using this medication for the treatment of low testosterone diagnoses only and not for bodybuilding and/or performer enhancement use. If ReGenesis HRT determines through random blood testing or any other means that I am using these medications for any other purpose than what they were prescribed for, I will be terminated as a patient immediately and will not be able to seek treatment ever again with ReGenesis HRT or any of its affiliates.
I agree that the ReGenesis HRT patient/physician relationship is not intended to replace the existing relationship with my current primary care provider (PCP) and my ReGenesis HRT treatment will be in conjunction with the care provided by my current PCP.
Todays Date
MM slash DD slash YYYY
ADAM questionnaire about symptoms of low testosterone (Androgen Deficiency in the Aging Male). This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms. If you answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.
Do you have a decrease in libido (sex drive)?
Yes
No
Do you have a lack of energy?
Yes
No
Do you have a decrease in strength and/or endurance?
Yes
No
Have you lost height?
Yes
No
Have you noticed a decreased "enjoyment of life"?
Yes
No
Are you sad and/or grumpy?
Yes
No
Are your erections less strong?
Yes
No
Have you noticed a recent deterioration in your ability to play sports?
Yes
No
Are you falling asleep after dinner?
Yes
No
Has there been a recent deterioration in your work?
Yes
No
IPSS Calculator
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you found you stopped and started again several times when you urinated?
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you found it difficult to postpone urination?
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had a weak urinary stream?
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how often have you had to push or strain to begin urination?
Not at all
Less than 1 time in 5
Less than half the time
About half the time
More than half the time
Almost always
Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
None
1 time
2 times
3 times
4 times
5 or more times
Total
$0.00
0 to 7 points:
Mild Symptoms
8 to 19 points:
Moderate Symptoms
20 to 35 points:
Severe Symptoms
Patient must read and acknowledge the below:
One side effect of testosterone treatment is infertility. Testosterone treatment decreases sperm production by decreasing levels of another hormone, follicelstimulating hormone (FSH), which is important for stimulating sperm production. In most cases, the infertility caused by testosterone treatment is reversible.
The use of testosterone-based contraceptive were
99% effective for preventing partner pregnancy
in what researchers say is the largest trial ever of a hormone-based male birth control approach. Testosterone therapy is usually given to men to treat a condition resulting from a lack of testosterone.
Patient Name
First
Last
Todays Date
MM slash DD slash YYYY