Biolife Health Center Comprehensive Health Assessment, Waiver and HIPAA Notice of Privacy Practices

The BioLife Advance Comprehensive Health Assessment covers the following:
1. General Medical Information
2. Medical Symptoms and Conditions
3. Diet
4. Sleep
5. Mental Health
6. Social History
7. Memory and Cognition
8. Exercise
9. Quality of Life Enjoyment and Satisfaction
10. Health Goals
11. Client Agreement
12. HIPAA Notice of Privacy Practices
Preparing for the Assessment

Reduce distractions
Do your best to give your full attention to the assessment. Whether you’re at home or at the clinic, ensure that your surroundings are calm and quiet, and put your personal devices on silent mode.

Get comfortable
Find an environment that is as comfortable as possible, and adjust your chair and screen so you are in the position that feels most natural.

Don’t overthink it
Think of the assessment like having your blood pressure measured - in other words, it’s a measurement as opposed to a test. If you do not know the answer to a question don't let it discourage you - keep going and try to maintain your focus throughout the duration of the assessment.

Answering the questions

Some questions are required. Other questions are not required but would greatly help us in assessing your overall health. If you do not know the answer, leave it blank or type "Don't remember", "None" or "N/A".

IMPORTANT

We recommend you fill out this form with someone you trust and knows you well. Spouses, parents, siblings, friends, and family members can help you answer some of the questions you may not have the answers to. The more accurate you answer this questionnaire, the better we will be able to implement your health plan.

If you need to search your records to answer some questions you do not have the answers now, do not stop. Fill out this form to the best of your abilities and send it in. You will be able to complete the information and make changes or complete missing information at your next visit to Biolfe Health Center.

Note: at the end of the questionnaire you will be able to print the completed form for your records. If you do not have access to a printer, you can print it to an Adobe PDF file depending on your computer system.
Full Name*

First NameLast Name
E-mail*
Marital Status*

SingleMarriedDivorcedWidowed
Gender*

MaleFemaleOther
Phone Number*
Emergency Contact Information
Name*

First NameLast NameRelationship to you
Contact Phone Number*
MEDICAL INFORMATION
Please check all that apply in each section
Date of Birth*

MonthDayYear
What is your age (in years)*
Height (Example 5'10") Answer 5 10*
Weight in Pounds(xxx)*
Name of primary Doctor or other health professionals you are currently seeing: (Enter 'None' if you do not have a primary Doctor*
For the following 3 questions, if you don't remember the month, date and year, you can just enter the month and year or just the year.
Date of your last physical examination by primary Doctor

MonthDayYear
Date of your last blood tests

MonthDayYear
Date of your last urine test

MonthDayYear
Date of your last stool test

MonthDayYear
The following three questions: 1 - 5 (1=poor / 5=excellent)

How do you rate your current level of health*

	1	2	3	4	5

1 is Worst, 5 is Best

How do you rate your current stress levels*

	1	2	3	4	5

1 is Worst, 5 is Best

How do you rate your current level of energy or vitality*

	1	2	3	4	5

1 is Worst, 5 is Best

Do you have known allergies?*
Please list any known allergies (if none, enter 'None')*
Please list any medications you are currently taking (e.g. anti-depressants, sleep medications, anti-anxiety medications, contraceptives, laxatives, blood thinners, etc) (if none, enter 'None')*
Please list any natural supplements you are currently taking for conditions such as anxiety, depression, insomnia, or stress (if none, enter 'None')*
What is your main health complaint? Please describe.*
Are there any of the following medical conditions in your family history that you are aware of? Please check all that apply.*

ArthritisAsthmaAutoimmune Disorders (e.g. lupus, rheumatoid arthritis)Bowel DisordersCancerDementia / AlzeihmersDepressionDiabetesHeart AttackHigh Blood PressureHigh CholesterolLow Blood PressureMental ConditionMental IllnessMuscular DystrophyObesityOsteoporosisOsteoporosisSkin DisordersStrokesThyroid Over ActiveThyroid Under ActiveNoneOther
Next: Symptoms

Sleep
Please check all that apply in each section
How many hours sleep do you get a night?*
Do you have trouble getting to sleep?*
Do you wake often, or get woken easily?*
Do you wake up in the middle of the night to go to the bathroom?*
Do you have to go to the bathroom during the night?*
Do you snore or have breathing problems during sleep?*
Do you sleep alone?*
Do you go to bed and wake up at the same time every day?*
Do you have frequent bad dreams or nightmares?*
Do you wake up feeling rested and refreshed?*
Have you had a sleep disorder test/evaluation?*
Next: Diet

Client Agreement/Waiver
The undersigned client agrees to abide by the guidelines of Biolife Health Center, LLC including the completion of the above medical questionnaire.

The undersigned client agrees that all use of Biolife Health Center facilities, services, and programs shall be undertaken at his (her) sole risk and Biolife Health Center shall not be liable for any injuries, accidents or deaths occurring to clients arising either directly or indirectly out of utilizing Biolife Health Center’s facilities, services and programs. The client, for himself (herself) and on behalf of his (her) executors, administrators, heirs and assigns, do hereby expressly release, discharge, waive, relinquish, and covenants not to sue Biolife Health Center, its officers, and agents for such claims, demands, injuries, damages or cause of action, with respect to use of Biolife Health Center’s facilities, programs, and services.

The undersigned Biolife Health Center client declares that they have completed the medical questionnaire above as required by Biolife Health Center and that they declare they are physically able to participate in physical activity and or utilize the whirlpool and dry/wet sauna rooms. Furthermore, Client declares that Biolife Health Center has advised client to obtain a medical clearance in the event they answer yes to any of the medical history questions, or they are unsure of their physical health and that client maintains that he (she) is physically capable of pursuing physical activity in Biolife Health Center without such steps being taken or has done so.
Date*

MonthDayYearHourMinutesAM/PM Option
Signature*

Clear
Next: HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices
Please Read and Sign Below
HIPAA Notice of Privacy Practices

BioLife Health Center

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Personally identifiable information about your health, your health care, and your payment for health care are called Protected Health Information. We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information. Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure.

Uses and Disclosures of Your Protected Health Information That Require Your Consent

The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:

For research purposes. In order to serve our patient community, we may want to use your health information in research studies. For example, researchers may want to see whether your treatment cured your illness. In such an instance, we will ask you to complete a form allowing us to use or disclose your information for research purposes. Completion of this form is completely voluntary and will have no effect on your treatment.

For marketing purposes. Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment. Additionally, without your permission, we will not sell or otherwise disclose your Protected Health Information to any person or company seeking to market its products or services to you.

Of psychotherapy notes. Without your permission, we will not use or disclose notes in which your doctor describes or analyzes a counseling session in which you participated, unless the use or disclosure is for on-site student training, for a disclosure required by court order, or for the sole use of the doctor who took the notes.

For any other purposes not described in this Notice. Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.

Your Rights Regarding Your Protected Health Information

You have the following rights related to your Protected Health Information:

To inspect and request a copy of your Protected Health Information. You may look at and obtain a copy of your Protected Health Information in most cases. You may not view or copy psychotherapy notes, information collected for use in a legal or government action, and information that you cannot access by law. If we use or maintain the requested information electronically, you may request that information in electronic format.

To request that we correct your Protected Health Information. If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file. We may deny your request if we find that the file is correct and complete, not created by us, or not allowed to be disclosed. If we deny your request, we will explain our reasons for the denial and your rights to have the request and denial and your written response added to your file. If we approve your request, we will change the file, report that change to you, and tell others that need to know about the change in your file.

To request a restriction on the use or disclosure of your Protected Health Information. You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request. An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service. If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations. We cannot limit uses or disclosures that are required by law.

To request confidential communication methods. You may ask that we contact you at a certain address or in a certain way. We must agree to your request as long as it is reasonably easy for us to do so.

To find out what disclosures have been made. You may get a list describing when, to whom, why, and what of your Protected Health Information has been disclosed during the past six years. We must respond to your request within sixty days of receiving it. We will only charge you for the list if you request more than one list per year. The list will not include disclosures made to you or for purposes of treatment, payment, health care operations if we do not use electronic health records, our patient directory, national security, law enforcement, and certain health oversight activities.

To receive notice if your records have been breached. UWM will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you., We will review any suspected breach to determine the appropriate response under the circumstances.

To obtain a paper copy of this Notice. Upon your request, we will give you a paper copy of this Notice.

If you have any questions about these rights, please contact us.

How to Complain About Our Privacy Practices

If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Protected Health Information, you may file a complaint with our Privacy Officer by writing to Biolife Health Center 16175 Golf Club Road Suite108, Weston, FL 33326

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.

We will take no action against you if you make a complaint to either or both of these persons.

How to Receive More Information About Our Privacy Practices

If you have questions about this Notice or about our privacy practices, please contact our Privacy Officer, David Priede, Ph.D. 305-707-7404.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

This signature is the only acknowledgment that you have received this notice of our Privacy Practices.
Print Name*
Effective Date*

MonthDayYear
Signature*

Clear
Please verify that you filed out this form*
Should be Empty:

MEDICAL INFORMATION

Please check all that apply in each section

Next: Symptoms

Symptoms Review

Please check all Symptoms you currently have in each section

Next: Head Injuries

Head Injuries

Please check all that apply in each section

Next: Sleep

Sleep

Please check all that apply in each section

Next: Diet

Diet

Please check all that apply in each section

Blood Sugar

Fatty Acids

Inflammation

Toxicity/Detoxification

Next: Mental Health

Mental Health

Please check all that apply in each section

If you are currently thinking about suicide, please reach out to a mental health professional or dial 911. National Suicide Prevention Lifeline 1-800-273-8255

Next: Social History

Social History

Please check all that apply in each section:

Next: Exercise

Exercise

Please check all that apply in each section

Next: Memory and Cognition

Next: Your Health Goals

Your Health Goals

Please check all that apply in each section

Next: Client Agreement/Waiver

Client Agreement/Waiver

Next: HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices

Please Read and Sign Below