Male New Patient Forms

Male New Patient Questionnaire
Name*
Date of Birth*

MonthDayYear
Date
Age
Occupation*
Home Address*
City*
State*
Zip*
Email Address*
example@example.com
Phone Number*
How did you hear about us*
Emergency Contact*
Relationship*
Emergency Contact Phone #*
Height*
Weight*
Do you smoke?*

YesNoI Quit
How Much
How Often
Age Started
Do you drink Alcohol?*

YesNo
How Much
How Often
Age Started
Any known drug allergies?*

YesNo
If Yes Please explain
Preferred Pharmacy
Name of Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.
Nutritional/Vitamin Supplements:
Current Medications:
Surgeries, list all & year
Current Hormone Replacement Therapy
Past HRT
Other Pertinent Information
Do you have a personal history of..? Please check all that apply.
Preventative Medical Care

Medical Exam in the last yearBone density in the last 12 months
High Risk Past Medical/Surgical History

Breast CancerProstate CancerOther
Birth Control Method

Birth Control PillsVasectomyOther
Medical Illnesses

High blood pressureHeart BypassHigh CholesterolHeart diseaseStroke and/or heart attackBlood clot or pulmonary emboliArrhythmiaAny form of hepatitis or hivLupus or any autoimmune diseaseFibromyalgiaTrouble passing urine or take Flomax or AvodartChronic liver diseaseDiabetesThyroid diseaseArthritisDepression/AnxietyPsychiatric disorderCancer

MRS Checklist - Before Hormone Replacement Therapy

	None	Mild	Moderate	Severe	Extremely Severe
Decline in your feeling of general well-being
Joint pain and muscular ache (lower back pain, joint pain)
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes)
Sleep problems
Increased need for sleep, often feeling tired
Anxiety (Inner restlessness, feeling panicky)
Irritability (feeling aggressive, easily upset about little things, moody)
Nervousness (inner tension, restlessness)
Physical Exhaustion/lack of vitality
Decrease in muscular strength (feeling weak)
Depressive mood
Feeling that you have passed your peak
Decrease in beard growth
Decrease in ability/frequency to perform sexually
Decease in number of morning erections
Decrease in sexual desire/libido

Please share any additional comments about your symptoms you would like to address
Do you have cold hands and feet?
Do you have daily bowel movements?
Do you have gas, bloating or abdominal pain after eating?
Please select your weekly activity level?
HIPAA INFORMATION AND CONSENT FORM
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services, www.hhs.gov. We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY AND UNDERSTAND THE INSTRUCTIONS ON THIS FORM.
Print name*
Signature*

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Date*

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Date
CONSENT FOR TREATMENT
I hereby state that I have honestly and without exaggeration or omission, completed the attached "New Patient Forms." I also state that I have disclosed all information that might reasonably be considered relevant to decisions made by Physicians regarding my care. I have disclosed all past illnesses, particularly those involving any form of cancer. I also state that I have disclosed all medications that I am taking at the present time and will inform Physician of any medications that may be prescribed now and in the future by other physicians. I also state that I have disclosed the past and present use of any substances including prescribed or nonprescription drugs, alcohol, steroids, vitamins, and dietary supplements. I hereby hold harmless and waive any claim or defense against Physician for any harm or injury I sustained because of my failure to fully disclose all relevant for facts about my physical and medical condition to Physician. I waive any claim or defense against Physician any I sustain because of my failure to comply with the method of treatment and dosage schedule prescribed by Physician. I agree to immediately cease any medical treatment prescribed by Physician in the event of any adverse response or side effect arising from prescribed treatment and to provide immediate notice of such adverse response or side effect to Physician via phone or office visit. I agree to comply with the prescribed instructions for use of all medications prescribed by Physician. I agree all medications are for my personal use and are not to be used by anyone other than myself. Iunderstand that the practice of medicine is not an exact science and that all diagnosis and treatment may involve risks of injury, including but not limited to permanent injury and death. I acknowledge that no guarantees have been made to me as to the result of the diagnostic testing analysis of test results, examination of medical history, or treatment by Physician. I acknowledge and accept that Physicians may not physically see me and will use lab testing, "New Patient Forms" a physical done by my primary care physician and provided by me to Physician, and telephonic conversations as the primary basis for diagnosis and treatment of any condition(s) I may have. Icertify that I have read and understand the questions in these forms; I acknowledge that I will have the opportunity to discuss my health history with my doctor. I will not hold my doctor or any other member of his/ her staff responsible for any errors or omissions that I have made in the completion of these forms.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
CONSENT FOR INTRAMUSCULAR INJECTION THERAPY
Your healthcare practitioner feels you may benefit from receiving Intramuscular (IM) vitamin injections. You have been diagnosed with or have an increased risk of having and/ or developing nutritional deficiencies, fatigue, weakness, muscular aches, or general tension/ stress which may be associated with your specific condition. The use of this therapy as it relates to your condition is considered an alternative treatment and has not been evaluated or approved by the Food and Drug Administered (FDA You have the right, as a patient, to be informed about your condition and the recommended alternative or non-conventional procedures to be used so that you may make an informed decision to undergo this procedure. This disclosure is meant to inform you of the benefits and any potential risks that could occur. Your practitioner may order a variety of vitamin injections, alone or in combination. A full list of ingredients and exact dosages is available at your request. Potential practitioners may order a variety of vitamin injections: Some individuals, based on clinical criteria, may have a nutritional deficiency, fatigue, or the need for physiological enhancement due to poor diet, disease, illness, infection, increased metabolism, or the need to alleviate stress or muscular tension. Administration of nutrient nutrient and vitamin IM injections can achieve more efficient delivery and achieve higher levels of absorption than taking oral supplements and greatly reduce the risk of gastrointestinal side effects that frequently occur with oral consumption. A standard vitamin IM injection includes vitamins, minerals, and amino acids such as Vitamin B12, Vitamin B6, Vitamin B Complex, Chromium, Adenosine, Magnesium, GABA; with potential additions/ subtractions per healthcare practitioner recommendation. Potential Risks of IM Vitamin Injections: As with any injection, discomfort at the needle insertion site, allergic reaction, redness, irritation, bruising, or localized infection may occur. On rare occasions, some individuals may experience dizziness, lightheadedness or nausea immediately following an injection; this is a common nervous system response and passes quickly. Contraindications of (IM) Vitamin Injections: May include bleeding disorders, pregnancy, chemotherapy, cancer history and certain allergies and are evaluated on an individual basis. Patient Statement: I agree to comply with any testing that may include laboratory or other diagnostic testing requested by my healthcare provider any adverse reaction or problem that may be related to my therapy or if I suspect I am pregnant.I understand the potential risks and benefits of the therapy and they have been explained to me, and all my questions have been adequately answered. I understand that I have not been guaranteed or promised any specific benefit to the administration of therapy. I attest that I have read this form, or had it read to me and I agree to the treatment recommended and I will not undergo any treatments that I do not fully understand.
Print Name*
Signature*

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Date*

MonthDayYear
Date
Cancellation Policy
We understand that plans can change, and sometimes you may need to cancel or reschedule your appointment with us. To ensure a smooth and fair cancellation process, we have established the following Cancellation Policy:

Cancellation notice and fees: To ensure fairness for all clients and to cover the costs associated with

last-minute cancellations, we have implemented a cancellation notice period.

We require 24-hour notice in case of any cancellations or changes to your appointment. We will abide by this same notice period, ensuring we don't cancel your appointment at the last minute.

If you cancel your appointment with less than 24-hour notice, you will be charged $75.

No-show fee: When an appointment is missed without prior notice, it affects our ability to accommodate other clients and maintain the high standards you expect from us. Therefore, we have implemented a no-show fee of $75

Emergency situation: We understand that emergencies can happen. If you need to cancel due to unforeseen circumstances, please contact us, and we will work with you to find a suitable solution.

How to reschedule or cancel: If you need to reschedule your appointment or reservation, please contact us as soon as possible. We will do our best to accommodate your request based on availability.

Contact information: Phone Number: 943-245-6058

Email: Ashley@allabouthealthjohnscreek.com or Chandler@allabouthealthjohnscreek.com

By booking an appointment with us, you agree to abide by our Cancellation Policy.

We value your business and strive to provide exceptional service. If you have any questions or concerns about our cancellation policy, please do not hesitate to contact us.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Preferred Pharmacy

Do you have a personal history of..? Please check all that apply.

HIPAA INFORMATION AND CONSENT FORM

CONSENT FOR TREATMENT

CONSENT FOR INTRAMUSCULAR INJECTION THERAPY

Cancellation Policy