Medical, Family, and Personal History Form for Low-Price Low T

Medical, Family, and Personal History for Low-Price Low T

For best care, please complete as thoroughly and accurately as possible.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
How did you hear about us?*
I have the following symptoms (check all that apply):*

FatigueWeight gainDecreased libido (low sex drive)Decreased sense of well-beingDepressed moodDifficulties with concentration and memoryLoss of muscular strengthLoss of bone densityHot flashes(Men only) Erectile dysfunction
I have had my testosterone level checked, and it was low.*

Yes (please provide us with the abnormal results via the upload box below)*No (please schedule a labs-only visit for us to check your testosterone level)**
*Please upload the previously abnormal testosterone result

NOTE: Or, you or your physician may fax it to us at 915-331-9481
Cancelof
**If you do not know if your testosterone is low, please first schedule a labs-only appointment (link at the bottom right of the page; the cost of the testosterone blood test is only $55 - payment due at the time of the visit), and there is no need to finish and submit this form unless it turns out to be low.
Name of Preferred Pharmacy*
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
Past Medical History (please list all significant medical problems you have had in the past, and include year of onset in parentheses):*
Include the following categories, if applicable: Cancer, cardiovascular, ear/nose/throat, endocrine, eyes, gastrointestinal, genitourinary, infections, lungs, muscle/bone/joint, neurological, psychiatric, skin, other
Past Surgical/Procedural History (please include year, name of surgeon, and city/state where it was performed):*
Are you allergic to any medicines?*

No known drug allergiesI have the following drug allergies (please include what specific reaction you had):
Medicines (both Prescription and Over-the-Counter) - please list all you are taking, including strength and frequency:*
Vitamins and supplements - please list all you are taking, including, if applicable, strength, amount, and frequency:*
Family History - please include any significant medical problems that your grandparents, parents, aunts, uncles, siblings, and children have or had (include who and age of onset in parentheses):*
Occupation/Company*
Hobbies and interests
Tobacco Use*

Never smokedCurrent smoker*Former smoker**I only use smokeless tobacco***
*If current smoker, what year did you start smoking, and how many cigarettes do you smoke per day on average?
**If former smoker, please include the year you quit, how many years you smoked, and how many packs per day on average you smoked during that time.
***If you use smokeless tobacco, please describe the type and frequency of use.
How often do you drink alcohol?*

NeverRarely0-3 times per weekMost days of the week or every day
If/when you drink, how many drinks do you have?

1-23-56 or more
Describe any use of recreational drugs or drug abuse.*

NeverPast*Current*
*Please describe drug history.
Briefly describe caffeine use. Type "None" if applicable.*
Briefly describe your diet and eating habits.*
What type of exercise do you do, how often, and for how long? Type "None" if applicable.*
Briefly describe your sleeping habits.*
If you have one, please upload a recent photo (head shot preferable, but not necessary) of yourself.

Cancelof
What else would you like us to know about you, health or otherwise?
Low-Price Low T
Disclosure and Consent
General Patient Authorization
I hereby authorize the medical team at Low-Price Low T to render health care to me according to the best judgment and orders of the physician or supervised physician assistant.*

YesNo
I understand that payment is made through the Hint Health payment management system, using the payment method you entered upon signing up. Payment methods that have expired must be rectified before any other services will be provided.*

YesNo
If a Medicare patient, I will carefully review and complete the Medicare Private Contract (link below - it essentially states that you understand that Dr. Cluff has opted out of Medicare and that you agree not to submit any bills incurred at Low-Price Low T for reimbursement from Medicare).*

YesNoN/A
Medicare Private Contract
I authorize Low-Price Low T to disclose medical information pertaining to my diagnosis and/or treatment, laboratory test results, medical history, immunization records, or any other such related information to those listed below (e.g.: Referring Physician, Specialists, Mother, Father, Spouse, Children, etc.).*

Yes. Please include name(s), relationship, phone number, and comments, if desired.I do not wish to have my medical information shared with anyone.
OK to disclose to:
Signature*

Clear
Should be Empty:

Medical, Family, and Personal History for Low-Price Low T