Male Patient Form Male Patient Intake Form Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Telephone(Required)Mobile TelephoneEmail (Receive Appointment Reminders) Spouse/PartnerIn the event we are unable to contact you by means you've provided above, we'd like to have the ability to contact you through your spouse. Please provide the necessary information about your spouse/partner below. First Middle Last Spouse/Partner DOB MM slash DD slash YYYY Spouse/Partner Telephone (mobile preferred)In case of emergency, whom should we notify? Contact NumberRelationship Signature Do you have/had hypertension? Yes No Do you have heart disease? Yes No Do you have mitral valve prolapse? Yes No Do you have a heart murmur? Yes No Have you ever been anemic? Yes No Have you ever had hepatitis/liver disease? Yes No Have you ever had rheumatic fever? Yes No Have you ever had thyroid problems? Yes No Do you have arthritis? Yes No Do you have/had kidney disease? Yes No Have you had any bladder or kidney problems? Yes No Do you have diabetes? Yes No Have you ever been treated for any psychiatric problems? Yes No Do you have any drug allergies? Yes No Have you had your cholesterol checked? Yes No Was it normal? Yes No Please list: Have you had any local anesthesia complications? (at dentist, etc.) Yes No Please describe: Do you have a primary care or family doctor? Yes No Please list name, phone, address (as much as possible)Please list any surgeries and/or hospitalizations:Hypertension (high blood pressure)? Yes No Family Members (Please name relation)Heart Disease? Yes No Family Members (Please name relation)Colon Cancer? Yes No Family Members (Please name relation)Diabetes? Yes No Family Members (Please name relation)Do you smoke? Yes No How much: How many years? Are you currently taking any medications? Yes No Do you have any drug allergies? Yes No If so please list?Please list all MAJOR surgeries (include year and reason)Do you drink alcohol? Yes No What types?How many drinks per week, on average, do you drink? Are you CURRENTLY using any form of hormone? Yes No Type: Estrogen Estradiol Estriol Estrone Type: Testosterone DHEA Progesterone Other Form Form: Cream Lozenge Oral (capsule) Shot Pellet Patch Other Form Have you PREVIOUSLY been on any form of HARMONE in the past? Yes No Please describe (which hormones, what form, what dose, when and for how long)Are you currently sexually active? Yes No Do you have a history of Sexually Transmitted Diseases? Yes No Have you had a sperm count? Yes No Have you had the mumps? Yes No Have you had Testicular Cancer? Yes No Do you have Prostate problems? Yes No If yes, please describe:Fatigue? Yes No Decrease in memory? Yes No Decrease sexual drive? Yes No Decrease in exercise response? Yes No Anxiety? Yes No Irritability? Yes No Mood swings? Yes No Migraines? Yes No Night sweats? Yes No How have you dealt with these symptoms?Have you experienced any weight gain in the past 1-2 years? Yes No If yes, please describe:Have you ever had your testerone level taken? Yes No If yes, please describe (when, result if known, etc)List of current medications:Do you initiate intercourse? Yes No Is intercourse satisfying? Yes No Do you achieve orgasm? Yes No Do you suffer from premature ejaculation? Yes No How often do you have intercourse? Do you have erectile dysfuntion? Yes No If yes, please describe:Is your sex drive the same as it was 5 years ago? If no, please describe:Signature (please type name) Male Testosterone Acknowledgement Form Although Pellet Hormone Therapy has been approved for human use, there are relatively few doctors who currently administer testosterone pellets in the United States. I realize that this is not the usual and customary means of prescribing testosterone. I realize that the advantages of testosterone for men often include: a.) behavioral changes including decreasing depression, decreasing anxiety and irritability, increasing energy and motivation, stabilizing mood, allowing one to cope better, improving one's self-image and self-worth, and enhancing one's stamina; b.) improvement in one's cognitive function, i.e. reducing "brain fog", improving short-term memory and allowing one to stay focused to complete a task; c.) physical effects such as decreasing total body fat, increasing lean body mass, increasing muscle mass, and increasing bone mass; and d.) sexual benefits such as increasing libido, increasing early morning erections, increasing firmness and duration of erections. I realize there are potential concerns with testosterone therapy and they include the possibility of enhancing a current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test and possibly a digital rectal exam should be done annually. If there is any question about possible prostate cancer, I consent to a follow-up with an ultrasound of the prostate gland. I realize that there is an issue with male athletes abusing testosterone. When taking large quantities of SYNTHETIC testosterone, there may be resultant heart problems and elevated cholesterol. However, low dose, non-oral, natural testosterone that is used in bio-identical hormone therapy has not been associated with these problems. Testosterone therapy may increase one's hemoglobin and hematocrit, or thicken one's blood. This can be reversed through donating blood periodically. This problem can be diagnosed with a blood test. Thus, a complete blood count may be done at least annually, and it is suggested that patients donate blood, a worthy endeavor, 1-3 times annually to prevent blood thickening from occurring. Especially in younger men, testosterone administration can suppress the development of sperm and sperm count could dramatically reduce while a person is on testosterone therapy. However, to date, this appears to be, in the majority of men, a reversible process. Once the testosterone is discontinued, the sperm recount is restored, usually in 6-12 months. This is extremely important to be aware of, in particular for younger men taking testosterone therapy. In this early stage, we have encouraged them to produce samples and have them frozen, just in case there is any permanent long-term effect on their situation. We have encouraged any men who are concerned about their fertility in the future to have a semen analysis prior to initiation of testosterone therapy. Currently, testosterone administration administration is not to be used as a form of male contraception. My signature certifies that I have read the above and acknowledge I have been encouraged to ask any questions regarding testosterone pellets. Individual results may of course vary.Patient Signature(Required) Date(Required) MM slash DD slash YYYY Consent For Hormone ImplantationI understand the reason for the procedure is hormone therapy using estradiol and/or testosterone hormones. I acknowledge that risks of this minor surgical procedure include possible infection and/or bleeding, among others. LOCAL ANESTHESIA is used and involves risk, most importantly a rare risk of reaction to medication causing death. I consent to the use of such anesthetics as may be necessary. I understand that no guarantee or assurance has been made as to the results of the procedure and that it may not cure the condition. PATIENT'S CONSENT: I have read and fully understand this consent form and understand I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form.Patient Signature(Required) Date(Required) MM slash DD slash YYYY Medicare and Medicaid WaiverAcknowledgment and Agreement: This office does not accept or bill Medical or Medicaid. In exchange for the services, the Patient agrees to make cash (credit or debit card) payments to Wellspring Restorative Health. Patient also, agrees, understands and expressly acknowledges the following: Patient agrees not to submit a claim (or a request that Physician submit a claim) to the Medicare program with respect to the services including, blood-work and laboratory services even if covered by Medicare Part B. Patient is not currently in a an emergency or urgent health care situation. Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services. Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement. Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to their Medicare-covered services furnished by other physicians or practitioners who have not opted-out. Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the services including, blood=work and laboratory services, and acknowledges that Physician will not submit a Medicare claim for the services and that no Medicare reimbursement will be provided. Patient understands that Medicare payment will not be made for any items or services furnished by tge physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted. Patient agrees to reimburse Physician for any costs and reasonable attorneys fees that result from violation of this Agreement by Patient or his beneficiaries. Patient Signature(Required) Date of Birth(Required) MM slash DD slash YYYY Today's Date(Required) MM slash DD slash YYYY HIPPA - Health Insurance Portability and Accountability ActYOUR RIGHTS- Under 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 who are involved in your health care or the paying of your care. ACCESS TO YOUR PERSONAL HEALTH INFORMATION - 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. OTHER USERS AND DISCLOSURES - We are permitted or required by law to use or disclose your personal health information, without our authorization, in the following circumstances: For public health activities (reporting of disease, injury, birth, death or suspicion of child abuse, neglect, or other 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(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 workers compensation claims We will adhere to all state and federal laws or regulations that provide protections to your privacy. We will only disclose HIV/AIDS related information, genetic testing information and information pertaining to your mental condition or any substance abuse problems as permitted by law. Patient Signature(Required) Date(Required) MM slash DD slash YYYY Δ
