Patient Medical History Form

First Name

Middle Name

Last Name

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Sex

Acknowledgment of a full physical in the last year

Height (inches)

Example: 68

Weight

Driver's License State

Driver's License Number

Patient protections and treatment decisions

Every patient has the right to be treated with dignity, respect, and consideration; be free from abuse, neglect, exploitation, coercion, manipulation, sexual abuse, and sexual assault; be free from restraint or seclusion except as permitted under R9-10-1012(B); be free from retaliation for filing a complaint with AZDHS or another entity; be protected from misappropriation of personal or private property by facility personnel, employees, volunteers, or students; consent to or refuse treatment, except in emergencies; withdraw or refuse consent before treatment begins; except in emergencies, receive information about alternatives, risks, and possible complications of proposed psychotropic medications or surgical procedures; receive information about the facility's health care directives policy and complaint process; consent before photographs are taken, except photographs for admission identification or administrative purposes; provide written consent before medical or financial records are released, except as otherwise permitted by law.

Additional patient rights

Every patient has the right to be free from discrimination based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis; receive treatment respecting individual choices, strengths, abilities, and individuality; receive privacy during treatment and personal care; review their medical record upon written request, consistent with Arizona law; receive a referral to another healthcare institution when the facility cannot provide needed physical or behavioral healthcare services; participate personally, or through a representative, in treatment planning and decisions; participate in or refuse research or experimental treatment; receive assistance from family members, representatives, or other individuals in understanding, protecting, or exercising these rights.

Questions or complaints

Patients may contact Endless Vitality's designated administrator to discuss concerns about care or the exercise of patient rights. Patients may also submit complaints to the Arizona Department of Health Services.

Patient Initials

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

HIPAA CONSENT TO LEAVE MESSAGE

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Medical History (conditions, surgeries, chronic disease)

Current Medications (include TRT, peptides, supplements)

Allergies (please list any allergies)

Current Medical Conditions (check all that apply)

Treatment Interest

Statement of Patient Acknowledgments by Treatment Modality

TRT Risk Acknowledgment: infertility risk understood, cardiovascular risk understood, requires lab monitoring, natural testosterone suppression.

Peptide Therapy Acknowledgment: off-label use understood, limited long-term data, injection risks understood, variable outcomes acknowledged.

GLP-1 / GIP Therapy Acknowledgment: GI side effects understood, gallbladder risk understood, pancreatitis risk understood, thyroid tumor warning understood.

Financial Policy Acknowledgment

Cash-pay clinic understood, No insurance billing, No guaranteed outcomes

HIPAA & Patient Rights Acknowledgment

HIPAA notice received, Right to refuse treatment understood, Medical record access understood, Complaint rights understood

Patient Signature