FEMALE INTAKE FORM

PRECISION

Regenerative & Functional Medicine
FEMALE INTAKE QUESTIONNAIRE
NAME
AGE
TODAY'S DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit year
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit year

EMAIL
example@example.com
Address

ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
PHONE (HOME)
Format: (000) 000-0000.
CELL
Format: (000) 000-0000.

HEIGHT
WEIGHT (LBS)
SOCIAL SECURITY NUMBER (SSN)
WHO IS YOUR PRIMARY CARE PHYSICIAN AND WHO DID YOU LAST SEE FOR CARE?

EMERGENCY CONTACT
RELATIONSHIP
PHONE (HOME)
Format: (000) 000-0000.
CELL
Format: (000) 000-0000.

CURRENT HEALTH CONCERNS

Please rank current and ongoing health concerns in order of priority.

Rows	Describe Problem	Severity (mild, moderate, severe)	Prior Treament/Approach	Success (excellent, good, fair)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

HEALTH GOALS
What do you hope to achieve in your visit with us?
ALLERGIES

Rows	Name of medication/supplement/food	Reaction
1.
2.
3.
4.
5.

EXERCISE

Current Exercise Program

Rows	Type	# Times Per Week	Time/Duration (Minutes)
Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (i.e. golf)

STRESS
Do you feel you have an excessive amount of stress in your life?
Do you feel you can easily handle the stress in your life?
RELATIONSHIPS
Marital status
CURRENT OCCUPATION

Rows	Number
Pregnancies
Miscarriages
Term births
Abortions
Living children
Premature birth
Vaginal deliveries
Cesarean

MENSTRUAL HISTORY
Age at first period
Date of last menstrual period
Length of menses
Time in between cycles
Cramping?

GYNECOLOGICAL SCREENING/PROCEDURES
Date of last mammogram
Was it normal or abnormal?
Date of last bone density
Bone density was
Other tests/procedures (list type and dates):

Musculoskeletal

Rows	Yes	Past
Fibromyalgia
Osteoarthritis
Chronic Pain
Other

Medical History (cont.) - Diagnostic Studies

Rows	Date	Comments
Bone Density
CT Scan
Colonoscopy
Cardiac Stress Test
EG
MRI
Upper Endoscopy
Upper GI Series
Chest X-ray
Other X-rays
Barium Enema
Other

Medical History (cont.) - Injuries

Rows	Date	Comments
Broken Bone(s)
Back Injury
Neck Injury
Head Injury
Other

Medical History (cont.) - Surgeries

Rows	Date	Comments
Appendectomy
Dental
Gallbladder
Hernia
Tonsillectomy
Joint Replacement
Heart Surgery
Other

Medical History (cont.) - Hospitalizations

Rows	Date	Reason
1.
2.
3.
4.
5.

MEDICATIONS/SUPPLEMENTS

Current Medications (include prescription and over-the-counter)

Rows	Medication	Dosage	Start Date (MO/YR)	Reason for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Nutritional Supplements (Vitamins/Minerals/Herbs etc.)

Rows	Name & Brand	Dosage	Start Date (MO/YR)	Reason for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Please list any medications and supplements you have taken in the past and explain why you stopped using them:
Have medications or supplements ever caused unusual side effects or problems?
If yes, please describe:

Have you used any of these regularly or for a long time?

Rows	Yes	No
NSAIDs (Advil/Motrin/Ibuprofen/Aspirin)
Tylenol (Acetaminophen)
Acid-Blocking Drugs (Zantac/Prilosec/Nexium)

FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS
PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE IS DEDICATED TO PROVIDING THE BEST POSSIBLE CARE AND SERVICE TO YOU. WE REGARD YOUR UNDERSTANDING OF ALL YOUR FINANCIAL RESPONSIBILITIES AS AN ESSENTIAL ELEMENT OF YOUR TREATMENT.

* WE HAVE MADE PRIOR ARRANGEMENTS WITH MANY INSURERS AND HEALTH PLANS (HMO & PPO) TO ACCEPT AN ASSIGNMENT OF BENEFITS. WE WILL BILL THOSE PLANS AND WILL ONLY REQUIRE YOU TO PAY THE AUTHORIZED COPAYMENT, COINSURANCE AND/OR DEDUCTIBLE AT THE TIME OF SERVICE. THE OFFICE POLICY IS TO COLLECT THIS COPAYMENT, COINSURANCE AND/OR DEDUCTIBLE WHEN YOU ARRIVE FOR YOUR APPOINTTMENT. THIS AMOUNT IS AN ESTIMATE AND IS BASED ON THE MOST RECENT INSURANCE VERIFICATION OBTAINED BY OUR OFFICE STAFF.

* IF YOUR INSURANCE POLICY REQUIRES A REFERRAL FOR PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE, PLEASE UNDERSTAND WE WILL REQUEST THIS REFERRAL FROM YOUR REFERRING PRACTITIONER PRIOR TO YOUR APPOINTMENT, BUT IT IS ULTIMATELY YOUR RESPONSIBILITY TO OBTAIN THIS REFERRAL. IF YOUR SERVICES ARE DENIED BECAUSE THE REFERRALWASNOT RECEIVED, YOU WILL BE RESPONSIBLE FOR THE FULL CHARGED AMOUNT.

* PRIVATE PAY PATIENTS ARE REQUIRED TO PAY IN FULL AT THE TIME OF SERVICE. A QUOTE WILL BE PROVIDED FOR ANY ANDALL PROCEDURES PRIOR TO YOUR APPOINTTMENT.

* WE ACCEPT VISA, MASTERCARD, AND DISCOVER. PLEASE BE ADVISED THAT THERE IS A $20 SERVICE CHARGE ON ALL RETURNED CHECKS.

* YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. AS A COURTESY, WE WILL FILE YOUR INSURANCE CLAIM FOR YOU, IF YOU ASSIGN THE BENEFITS TO OUR DOCTOR. IF YOUR INSURANCE COMPANY DOES NOT PAY OUR OFFICE WITHIN 90 DAYS, YOU WILL BE RESPONSIBLE FOR PAYMENT. IF WE LATER RECEIVE A CHECK FROM YOUR INSURER, WE WILL REFUND ANY OVERPAYMENT.

* ALL HEALTH PLANS ARE NOT THE SAME AND DO NOT COVER THE SAME SERVICES. IN THE EVENT THAT YOUR HEALTH PLAN DETERMINES A SERVICE TO BE "NOT COVERED" YOU WILL BE RESPONSIBLE FOR THE COMPLETE CHARGE. PAYMENT IS DUE UPON RECEIPT OF A STATEMENT FROM OUR OFFICE.

* IF YOU HAVE A MEDICAL PROCEDURE PERFORMED BY OUR PHYSICIAN AT A LOCATION OTHER THAN OUR OFFICE YOU AND/OR YOUR INSURANCE COMPANY WILL RECEIVE TWO BILLS, ONE FROM OUR PHYSICIAN FOR HIS PROFESSIONAL SERVICES AND ONE FROM THE FACILITY WHERE THE PROCEDURE WAS PERFORMED.

* FOR ALL SERVICES RENDERED TO MINOR PATIENTS, THE PARENT AND/OR LEGAL GUARDIAN WILL BE RESPONSIBLE FOR PAYMENT.

* IF YOU RECEIVE A STATEMENT FROM PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE THE BALANCE NEEDS TO BE PAID IN FULL WITHIN 30 DAYS OF RECEIPT UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. ANY REMAINING BALANCES DUE AFTER 90 DAYS WILL BE CONSIDERED DELINQUENT AND WILL BE TURNED OVER TO AN OUTSIDE COLLECTION AGENCY. FUTURE APPOINTMENTS WILL NOT BE SCHEDULED UNTIL BALANCES HAVE BEEN PAID IN FULL OR A WRITTEN PAYMENT PLAN HAS BEEN AGREED TO BY OUR OFFICE. PLEASE BE SURE TO UPDATE ANY CONTACT CHANGES WITH OUR OFFICE STAFF so YOU CAN BE REACHED REGARDING YOUR BALANCE.

* IN ORDER TO PROVIDE THE BEST POSSIBLE SERVICE AND AVAILABILITY TO ALL OUR PATIENTS, PLEASE CALL US AS EARLY AS POSSIBLE IF YOU KNOW YOU WILL NEED TO RESCHEDULE YOUR APPOINTMENT. PLEASE SEE THE ATTACHED CANCELATION NO SHOW POLICIES AND FEES.

* I HEREBY ASSIGN ALL MEDICAL AND SURGICAL BENEFITS, TO INCLUDE MAJOR MEDICAL BENEFITS, TO WHICH I AM ENTITLED. I HEREBY AUTHORIZE AND DIRECT MY INSURANCE CARRIER(S), INCLUDING MEDICARE, PRIVATE INSURANCE AND OTHER HEALTH/ MEDICAL PLAN, TO ISSUE PAYMENT CHECK(S) DIRECTLY TO PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE FOR MEDICAL SERVICES RENDERED TO MYSELF AND/ OR MY DEPENDENTS REGARDLESS OF MY INSURANCE. IN THE EVENT THAT THE INSURANCE PAYMENT IS SENT DIRECTLY TO ME, I REALIZE THAT I WILL BE BILLED PERSONALLY UNTIL THE BALANCE IS PAID.

I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS OF THE PRACTICE AND I AGREE TO BE BOUND BY ITS TERMS. I ALSO UNDERSTAND AND AGREE THAT THE PRACTICE MAY AMEND SUCH TERMS FROM TIME-TO-TIME.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

AUTOMATIC BILLING AUTHORIZATION FORM
I authorize you to charge my bill directly to the credit card(s) listed below:
Primary Card Account
Name on credit card (exactly as printed)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Card Account
Name on credit card (exactly as printed)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Card Number
Expiration Date (MM/YY)
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Bill all charges to the above card(s). Since the payment amount may vary, I will receive written notification of the amount and date of the next charge prior to each scheduled transaction date.
- This authorization is valid until I provide you with written cancellation.
- I AUTHORIZE THE CHARGE OF ALL COPAYS, CO-INSURANCE OR DEDUCTIBLE AMOUNTS DUE FOR ALL IN OFFICE AND TELEMEDICINE VISITS
- I AUTHORIZE THE CHARGE OF ALL NO-SHOW OR MISSED APPOINTMENT FREES. I HAVE REVIEWED AND SIGNED THE CANCELATION AND NO-SHOW POICIES AND FEE DOCUMENT.
- I AUTHORIZE THE CHARGE FOR ALL CLINIC LAB FEES FOR LABS DRAWN AT PRFM.
- I AUTHORIZE THE CHARGE FOR ANY PEPTIDES, HRT PRODUCTS THAT ARE ORDERED AND PAID FOR BY PRFM AND SHIPPED DIRECTLY TO MY HOME.
- I AUTHORIZE THE CHARGE FOR ANY UNPAID BALANCES OVER 30 DAYS OLD.
PATIENT SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

CANCELLATION AND NO SHOW POLICIES AND FEES
THIS IS A REMINDER OF OUR POLICY REGARDING MISSED APPOINTMENTS. WHEN ONE PATIENT MISSES THEIR APPOINTMENT AND DOES NOT LET US KNOW, OR WHEN ONE PATIENT CANCELS THEIR APPOINTMENT LATE (LESS THAN 24 HOURS PRIOR TO THE APPOINTMENT), IT NOT ONLY AFFECTS OUR STAFF, BUT ALSO OTHER PATIENTS.

AS YOU KNOW, OUR PATIENTS ARE IN PAIN. THEY LIKE TO BE SEEN AND TREATED AS SOON AS POSSIBLE. WE DO OUR BEST TO SEE AND TREAT EVERYBODY AS SOON AS WE CAN, BUT ALSO ALLOW ENOUGH TIME ON OUR SCHEDULE FOR EVERY PATIENT TO BE HEARD AND EXAMINED, AND FOR QUESTIONS TO BE ANSWERED. WE ARE RESPECTFUL OF OUR PATIENTS' TIME, AND WE ASK OUR PATIENTS TO BE RESPECTFUL OF OUR TIME.

WHEN SOMEBODY DOES NOT CALL TO CANCEL THEIR APPOINTMENT AND SIMPLY JUST DOES NOT SHOW UP, OR CALLS AND CANCELS THEIR APPOINTMENT AT THE LAST MINUTE, WE CANNOT SCHEDULE ANOTHER PATIENT ON SUCH SHORT NOTICE. WE LOSE TIME THAT DAY AND SOMEBODY ELSE CONTINUES TO WAIT TO SEE US, WHILE SUFFERING IN PAIN.

CHARGING FOR MISSED APPOINTMENTS IS NOT SOMETHING WE LIKE TO DO. IT CAN BE AVOIDED WITH A MINIMUM OF COURTESY AND GOOD COMMUNICATION. PLEASE HELP US CONTINUE TO TREAT YOU AND EVERYBODY ELSE AT THE STANDARDS YOU DESERVE.

FOLLOW UP APPOINTMENTS

NO-SHOW OR MISSED WITHOUT 24 HOURS NOTICE WILL BE CHARGED $150.00

CANCELED WITH LESS THAN 24 HOURS NOTICE WILL BE CHARGED $100.00

IF YOU ARRIVE MORE THAN 15 MINUTES LATE FOR A FOLLOW UP APPOINTMENT, YOUR APPOINTMENT MAY BE RESCHEDULED AND YOU WILL BE CHARGED $50.00 (THIS IS AT THE PROVIDER'S DISCRETION)

PROCEDURE APPOINTMENTS

NO-SHOW OR MISSED WITHOUT 24 HOURS NOTICE WILL BE CHARGED $200.00

CANCELED WITH LESS THAN 24 HOURS NOTICE WILL BE CHARGED $150.00

NEW PATIENT APPOINTMENTS

NO-SHOW OR MISSED WITHOUT 24 HOURS NOTICE WITH BE CHARGED $250.00

CANCELED WITH LESS THAN 24 HOURS NOTICE WILL BE CHARGED $225.00

FEES NEED TO BE PAID IN FULL BEFORE APPOINTMENTS WILL BE RESCHEDULED
PATIENT SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

ACKNOWLEDGMENT OF RECEIPT AND PRIVACY NOTICE
I,enter full name*UNDERSTAND THAT AS PART OF MY HEALTH CARE, PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE ORIGINATES AND MAINTAINS PAPER AND/OR ELECTRONIC RECORDS DESCRIBING MY HEALTH HISTORY, SYMPTOMS, EXAMINATION AND TEST RESULTS, DIAGNOSES, TREATMENT, AS WELL AS PLANS FOR FUTURE CARE. I UNDERSTAND THAT THIS INFORMATION SERVES AS:
- A BASIS FOR PLANNING MY TREATMENT;
- A MEANS TO FACILITATE COMMUNICATION AMONG THE MANY HEALTHCARE PROFESSIONALS WHO CONTRIBUTE TO MY CARE;
- A SOURCE OF INFORMATION FOR APPLYING MY DIAGNOSIS AND SURGICAL INFORMATION TO MY BILL;
- A MEANS BY WHICH A THIRD-PARTY PAYER CAN VERIFY THAT SERVICES BILLED WERE ACTUALLY PROVIDED;
- A TOOL FOR HEALTHCARE OPERATIONS OF PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE SUCH AS ASSESSING QUALITY OF CARE AND REVIEWING THE COMPETENCE OF HEALTHCARE PROFESSIONALS.
I UNDERSTAND THAT AS PART OF PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS, IT MAY BECOME NECESSARY TO DISCLOSE MY PROTECTED HEALTH INFORMATION TO ANOTHER ENTITY FOR THE PURPOSES STATED ABOVE. I UNDERSTAND I HAVE THE RIGHT TO REVIEW A NOTICE OF PRIVACY PRACTICES THAT PROVIDES A MORE COMPLETE DESCRIPTION OF HOW PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE MAY USE AND DISCLOSE MY PROTECTED HEALTHCARE INFORMATION. I FURTHER UNDERSTAND THAT PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE RESERVES THE RIGHT TO CHANGE ITS NOTICE OF PRIVACY PRACTICES. SHOULD PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE CHANGE ITS NOTICE OF PRIVACY PRACTICES, AN AMENDED COPY WILL BE POSTED IN A PROMINENT LOCATION IN THE PRACTICE SITE, OR, UPON MY REQUEST, AN AMENDED COPY WILL BE SENT TO THE ADDRESS I HAVE PROVIDED. I AGREE THAT PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE MAY DO THE FOLLOWING UNLESS I SPECIFICALLY GIVE DIRECTION PROHIBITING SUCH ACTIVITY:
- SEND VISIT REMINDERS AND TEST RESULTS TO THE ADDRESS I HAVE PROVIDED.
- SEND ROUTINE CORRESPONDENCE, SUCH AS BILLING STATEMENTS, TO THE ADDRESS I HAVE PROVIDED.
- LEAVE MESSAGES ON ANSWERING MACHINE OR VOICEMAIL ASSOCIATED WITH THE TELEPHONE NUMBERS I HAVE PROVIDED TO EITHER CONFIRM APPOINTMENTTS OR TO REQUEST THAT I CALL THE PRACTICE FOR MEDICAL OR BILLING MATTERS.
- SPEAK TO OR LEAVE MESSAGE WITH THE FAMILY MEMBERS/FRIENDS LISTED BELOW:
NAME
RELATIONSHIP TO PATIENT
ALTERNATE CONTACT NUMBER
Format: (000) 000-0000.
NAME
RELATIONSHIP TO PATIENT
ALTERNATE CONTACT NUMBER
Format: (000) 000-0000.
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

INFORMED CONSENT FOR ANABOLIC HORMONE THERAPY
IT IS IMPORTANT THAT YOU UNDERSTAND THE POTENTIAL RISKS OF STARTING HORMONE REPLACEMENT THERAPY, ALONG WITH THE MANY BENEFITS WE HAVE ALREADY DISCUSSED. THERE ARE ALTERNATIVES TO HORMONE THERAPY FOR MANY SYMPTOMS WOMEN MAY SEEK TREATMENT FOR, WHICH HAVE VARYING DEGREES OF EFFICACY, THAT HAVE BEEN DISCUSSED WITH YOU. IF YOU ARE NOT CLEAR ON ALTERNATIVES, PLEASE FOLLOW UP WITH YOUR PROVIDER PRIOR TO SIGNING THIS FORM IF YOUR INTERESTED IN THEM.

BECAUSE OF THE RAPIDLY CHANGING IDEAS ABOUT THE SAFETY AND EFFECTIVENESS OF HORMONE THERAPY FOR ANYTHING OTHER THAN BIRTH CONTROL, IT IS IMPORTANT THAT YOU HAVE INFORMATION ABOUT THE RISKS AND BENEFITS OF HORMONE THERAPY BEFORE YOU TAKE THE THERAPY. THERE ARE VARIOUS FORMS OF BOTH ESTROGEN, PROGESTERONE, AND OTHER SEX HORMONES AVAILABLE IN HORMONE REPLACEMENT THERAPY (HRT). AT PRECISION REGENERATIVE AND FUNCTIONAL MEDICINE, WE ONLY USE BIOIDENTICAL PROGESTERONE AND NON-ORAL, BIOIDENTICAL ESTROGEN.

HRT IS OFTEN PRESCRIBED TO WOMEN DURING PERIMENOPAUSE (THE TIME FROM FIRST SYMPTOMS TO UP TO SEVERAL YEARS BEYOND THE LAST PERIOD) AND MENOPAUSE (STARTING ONE YEAR AFTER THE LAST PERIOD) FOR SYMPTOMS OF HOT FLASHES, BONE LOSS, AND OSTEOPOROSIS OR THEIR PREVENTION, AND CARDIOVASCULAR DISEASE. HRT IS APPROVED BY THE FDA ONLY FOR HOT FLASHES AND OSTEOPOROSIS. USING IT FOR OTHER SYMPTOMS OR PROBLEMS IS CONSIDERED "OFF-LABEL" USE, AND THE BURDEN IS ON THE PHYSICIAN TO BE SURE THAT THERE IS ADEQUATE SCIENCE TO SUPPORT THE USE IN A GIVEN SITUATION. NEEDLESS TO SAY, THERE WILL BE DIFFERENCES IN OPINION ABOUT HOW MUCH SCIENCE IS NECESSARY.

IT IS NOW THOUGHT THAT THE COMBINATION OF ESTROGEN AND SYNTHETIC PROGESTINS INCREASE THE RISK OF BREAST CANCER OVER ESTROGEN ALONE. ESTROGEN REPLACEMENT THERAPY (ERT) IS USED PRIMARILY FOR WOMEN WHO HAVE HAD THEIR UTERUS REMOVED AND FOR WHOM ESTROGEN ALONE DOES NOT CAUSE NEGATIVE SYMPTOMS. RECENT LITERATURE SHOWS NO INCREASED RISK OF BREAST CANCER WITH THE USE OF TRANSDERMAL ESTRADIOL AND MICRONIZED BIOIDENTICAL PROGESTERONE.

IN SOME INSTANCES, TESTOSTERONE AND/OR DHEA IS ADDED TO THE HRT FOR WOMEN. THERE IS EVIDENCE THAT GIVING EXOGENOUS TESTOSTERONE TO WOMEN MAY INCREASE THE RISK FOR DEVELOPING HEART DISEASE AND CANCER, BUT DATA ARE INSUFFICIENT FOR A CONCENSUS. ON THE CONTRARY, MUCH EVIDENCE IS AVAILABLE TO INDICATE POSITIVE EFFECTS OF THESE INTERVENTIONS ON CARDIOVASCULAR HEALTH AND FUNCTION. HISTORY OR CURRENT ACNE, ABNORMAL FACIAL HAIR GROWTH, OR OTHER SIGN OF HYPERANDROGENISM MAY INDICATE A RELATIVE CONTRAINDICATION. THERE IS ALSO LITERATURE ON THE OTHER SIDE INDICATING THAT RESTORING TESTOSTERONE TO PHYSIOLOGIC LEVELS IS BREAST PROTECTIVE IN ADDITION TO INCREASING COGNITIVE HEALTH, HAIR HEALTH, SEXUAL FUNCTION, AND OVERALL PHYSICAL HEALTH. IN FACT, RISK FOR CARDIOVASCULAR DISEASE CAN BE REDUCED BY UP TO 50% ON HORMONE REPLACEMENT THERAPY.

WHEN HORMONE LEVELS ARE BROUGHT BACK TO "NORMAL" FOR REPRODUCTIVE AGE, THERE IS MUCH EVIDENCE THAT YOUR OVERALL HEALTH WILL BENEFIT. FOR EXAMPLE, THE RISK OF OSTEOPOROSIS AND FRACTURES DECREASES, NO SMALL THING WHEN ACCIDENTAL FALLING IS THE LEADING CAUSE OF DEATH IN PEOPLE OVER 65. HRT IS THE MOST EFFECTIVE TREATMENT FOR HOT FLASHES, AND THERE MAY BE OTHER LONG-TERM BENEFICIAL EFFECTS OF TREATMENT. HOWEVER, IF YOUR SEX HORMONES ARE ALREADY NORMAL, ADDING ADDITIONAL HORMONE TO ADDRESS SYMPTOMS SUCH AS HOT FLASHES MAY INCREASE YOUR RISK OF DISEASE LIKE CANCER OR PROBLEMS LIKE BLOOD CLOTTING.

THE FOLLOWING IS A LIST OF THE POTENTIAL SIDE EFFECTS OF HORMONE THERAPY IN WOMEN:
NEUROPSYCHOLOGICAL
- SOME PATIENTS CAN BECOME MORE AGGRESSIVE OR HAVE OTHER SUBTLE MENTAL HEALTH CHANGES WHILE ON ANABOLIC HORMONE THERAPY. IF YOU NOTICE NEGATIVE CHANGES IN MOOD OR OVERALL MENTAL HEALTH, CONTACT THE OFFICE TO GET A FOLLOW UP APPOINTMENT.
INITIAL
MUSCULOSKELETAL
- IT IS LIKELY THAT HORMONE THERAPY WILL CAUSE AN INCREASE IN LEAN MUSCLE TISSUE, WHICH WILL MANIFEST IN A HEAVIER WEIGHT. AT THE SAME TIME, WEIGHT LOSS MAY ALSO OCCUR DUE TO THE REDUCTION IN FAT MASS.
- BLOATING AND SWELLING MAY OCCUR AS A RESULT OF HORMONE THERAPY. THIS IS TYPICALLY TRANSITORY AND SHOULD RESOLVE WITH MODIFICATION OF DOSING.
INITIAL
ANDROGENIC
- SOME ANABOLIC AGENTS HAVE BEEN NOTED TO DEEPEN THE VOICE THROUGH CHANGES IN THE VOCAL CORDS. THIS WILL INITIALLY MANIFEST IN HOARSENESS AND/OR PITCH CHANGES. SUCH EFFECTS CAN BE PERMANENT IF THE INSTIGATING AGENT IS NOT STOPPED.
INITIAL
GENITOURINARY
- IF YOU ARE PREMENOPAUSAL AND DESIRING FERTILITY, SOME COMPONENTS OF HORMONE REPLACEMENT MAY PREVENT OVULATION FROM OCCURING. THESE CHANGES REVERSE AFTER CEASING THERAPY, OR CYCLING.
- THE USE OF VAGINAL HORMONE ADMINISTRATION MAY LEAD TO INCREASE IN YEAST INFECTIONS. IF YOU ARE PRONE TO YEAST INFECTIONS, ADDITIONAL COMPOUNDS, LIKE LACTOBACILLUS ACIDOPHILUS OR BORIC ACID CAN BE ADDED TO THE VAGINAL INSERT.
- SOME ANABOLIC AGENTS HAVE BEEN NOTED TO INCREASE CLITORAL SIZE. SUCH EFFECTS CAN BE PERMANENT IF THE INSTIGATING AGENT IS NOT STOPPED. FOR SOME WOMEN WITH DIFFICULTY ACHIEVING ORGASM, CLITORAL ENLARGEMENT MAY BE DESIRED.
INITIAL
HEMATOLOGIC
- BONE MARROW CAN BE STIMULATED WITH HORMONE THERAPY CONTAINING TESTOSTERONE OR OTHER ANABOLIC STEROIDS, SO BLOOD CELL COUNTS MUST BE MONITORED.
- INCREASED RISK FOR CLOTTING AND THROMBOEMBOLIC EVENTS HAVE BEEN OBSERVED WITH HORMONE REPLACEMENT CONTAINING ESTROGEN AND SYNTHETIC PROGESTINS.
INITIAL
HEPATIC
- ORALLY AVAILABLE ANABOLIC HORMONES LIKE OXANDROLONE (ANAVAR) CAN IRRITATE THE LIVER IN SOME PEOPLE, SO YOUR LIVER FUNCTION WILL BE TESTED ROUTINELY IF YOU ARE PRESCRIBED SUCH A FORMULATION.
INITIAL
DERMATOLOGIC
- BECAUSE TESTOSTERONE CAN METABOLIZE INTO DIHYDROTESTOSTERONE (DHT), SOME FORMS OF ANABOLIC HORMONE THERAPY ARE ASSOCIATED WITH HAIR LOSS ON THE SCALP AND HAIR GROWTH ON THE FACE. ACNE MAY ALSO OCCUR.
INITIAL
CARDIOVASCULAR
- SOME STUDIES HINT AT INCREASED RISK OF HEART ATTACK AND STROKE IN WOMEN ON HORMONE REPLACEMENT. HOWEVER, THERE IS ALSO A COPIOUS AMOUNT OF DATA THAT SUGGESTS THE OPPOSITE. LIPOPROTEIN, INFLAMMATORY, AND ENDOTHELIAL PARAMETERS WILL BE MEASURED AT LEAST EVERY 6 MONTHS TO ASSESS FOR CHANGES.
INITIAL
ONCOLOGIC
- ESTROGEN, PROGESTERONE, AND TESTOSTERONE THERAPY MAY INCREASE THE RISK FOR CANCERS OF THE BREAST, OVARY, AND UTERUS. WHILE THESE RISKS VARY ACCORDING TO THE TYPES OF HORMONES USED AND THEIR ROUTE OF ADMINISTRATION, IT IS NONETHELESS A RISK THAT MUST BE CONSIDERED.
INITIAL

PLEASE READ THE FOLLOWING AND SIGN:
I HAVE DISCUSSED THE REASONS FOR TAKING SEX HORMONES WITH MY PROVIDER AND UNDERSTAND WHY HE IS PRESCRIBING THEM. I ALSO DISCUSSED THE RISKS ASSOCIATED WITH TAKING HORMONES, INCLUDING BUT NOT LIMITED TO INCREASED RISK OF BREAST, OVARIAN, OR ENDOMETRIAL CANCER, BLOODING CLOTTING, STROKE, OR HEART ATTACK.

I UNDERSTAND THAT THERE ARE BLACK BOX WARNINGS INDICATING INCREASED RISK FOR THE CONDITIONS IN BOLD FOR THE FOLLOWING MEDICATIONS:

1. OXANDROLONE

A. ARTERIOSCLEROSIS; CARDIAC DISEASE; CORONARY ARTERY DISEASE; HEART FAILURE; HYPERCHOLESTEROLEMIA; MYOCARDIAL INFARCTION, PERIPHERAL EDEMA.

2. TESTOSTERONE/ANABOLIC STEROID CREAMS

A. VIRILIZATION OF CHILDREN DUE TO SECONDARY EXPOSURE. CHILDREN SHOULD AVOID CONTACT WITH UNWASHED OR UNCLOTHED APPLICATION SITES.

3. ESTRADIOL

A. ENDOMETRIAL CANCER, CARDIOVASCULAR DISORDERS, BREAST CANCER, PROBABLE DEMENTIA.

I UNDERSTAND THAT THERE ARE DIFFERENT RISKS IF I TAKE SYNTHETIC PROGESTINS, BIOIDENTICAL PROGESTERONE, OR TESTOSTERONE ALONGSIDE ESTROGEN, AND THEY MAY BE HIGHER OR LOWER THAN TAKING ESTROGREN ALONE. I HAVE DISCUSSED THAT MY PROVIDER WILL DO EVERYTHING THEY KNOW TO DECREASE AND MINIMIZE THE RISKS OF HRT, BUT THAT THERE ARE NO GUARANTEES THAT THESE MEASURES WILL BE EFFECTIVE AT PREVENTING THE NEGATIVE OFF-TARGET EFFECTS MENTIONED ABOVE OR OTHERS THAT WE DO NOT YET KNOW ABOUT. I UNDERSTAND THE DIAGNOSTIC TESTS THAT ARE AVAILABLE THAT WOULD HELP QUANTIFY MY RISK FOR POTENTIAL ADVERSE EFFECTS AND THAT GETTING THEM PERFORMED OR NOT IS MY CHOICE. I ALSO ACKNOWLEDGE THAT THIS IS OFF LABEL USE AND IS NOT CONSIDERED THE STANDARD OF CARE FOR MY CLINICAL PRESENTATION. I ACCEPT THE RISKS AND UNKNOWNS OF TAKING HORMONE THERAPY AND WISH TO PROCEED WITH THERAPY.

*IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT STARTING THERAPY, DO NOT SIGN THIS FORM UNTIL YOU HAVE DISCUSSED THEM WITH YOUR PROVIDER.
PATIENT NAME
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	1	2-4	>4
Coffee (cups per day)
Tea (cups per day)
Caffeinated Sodas - Regular or diet (cans per day)

Rows	Mother	Father	Brother(s)	Sister(s)	Child	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather	Other
Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Autoimmune Disease
Arthritis
Kidney Disease
Thyroid Problems
Seizures/Epilepsy
Psychiatric Disorders
Anxiety
Depression
Asthma
Allergies
Eczema
ADHD
Autism
Irritable Bowel Syndrome
Dementia
Substance Abuse
Genetic Disorders
Other

Rows	Yes	Past
Irritable Bowel Syndrome
GERD (Reflux)
Crohn's Disease/Ulcerative Colitis
Peptic Ulcer Disease
Celiac Disease
Gallstones
Other

Rows	Yes	Past
Bronchitis
Asthma
Emphysema
Pneumonia
Sinusitis
Sleep Apnea
Other

Rows	Yes	Past
Kidney Stones
Gout
Interstitial Cystitis
Frequent Yeast Infections
Frequent Urinary Tract Infections
Sexual Dysfunction
Sexually Transmitted Diseases
Other

PRECISION

FEMALE INTAKE QUESTIONNAIRE

CURRENT HEALTH CONCERNS

HEALTH GOALS

ALLERGIES

LIFESTYLE REVIEW

EXERCISE

NUTRITION

TOBACCO/NICOTINE

ALCOHOL

STRESS

RELATIONSHIPS

WOMEN'S HISTORY

MENSTRUAL HISTORY

GYNECOLOGICAL SCREENING/PROCEDURES

FAMILY HISTORY

MEDICAL HISTORY: ILLNESSES/CONDITIONS

MEDICATIONS/SUPPLEMENTS

FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS

AUTOMATIC BILLING AUTHORIZATION FORM

Primary Card Account

Secondary Card Account

CANCELLATION AND NO SHOW POLICIES AND FEES

AUTHORIZATION FOR RELEASE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Facility or Physician

ACKNOWLEDGMENT OF RECEIPT AND PRIVACY NOTICE

INFORMED CONSENT FOR ANABOLIC HORMONE THERAPY

PLEASE READ THE FOLLOWING AND SIGN:

Rows	Yes	Past
Diabetes
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Infertility
Metabolic Syndrome/Insulin Resistance
Eating Disorder
Hypoglycemia
Other

Rows	Yes	Past
Rheumatoid Arthritis
Chronic Fatigue Syndrome
Food Allergies
Environmental Allergies
Multiple Chemical Sensitivities
Autoimmune Disease
Immune Deficiency
Mononucleosis
Hepatitis
Other

Rows	Yes	Past
Angina
Heart Attack
Heart Failure
Hypertension (High Blood Pressure)
Stroke
High Blood Fats (Cholesterol, Triglycerides)
Rheumatic Fever
Arrythmia (Irregular Heart Rate)
Murmur
Mitral Valve Prolapse
Other

Rows	Yes	Past
Epilepsy/Seizures
ADD/ADHD
Headaches
Migraines
Depression
Anxiety
Autism
Multiple Sclerosis
Parkinson's Disease
Dementia
Other

Rows	Yes	Past
Lung
Breast
Colon
Prostate
Skin
Other