The Heart Shop AZ



242 Whipple St., Suite 1Prescott, AZ 86301Office: 928-708-9355 Fax: 928-778-0278 OFFICE HOURSMondayTuesdayWednesdayThursdayFriday7:30 – 5:007:30 – 5:007:30 – 5:007:30 – 5:00ClosedPHONES: Our Phones are available Monday – Thursday during normal business hours listed above. EMERGENCIES: If you are experiencing a life-threatening emergency, please call 911. All other calls, please call our office to speak with the medical assistant.SCHEDULING AN APPOINTMENT: Requesting an appointment can be done by calling the office during normal business hours. Should you need to cancel or reschedule an appointment, we do ask that you notify our office at least 24 hours prior.WHAT TO BRING TO YOUR NEW PATIENT APPOINTMENT: In order to make your appointment as efficient as possible, please bring or the following:Your insurance card(s) and valid identificationNew patient paperwork (available on the website) – Filled out prior to appointmentUpdated medication listCopay, deductible, and/or coinsurance is required at the time services are rendered. For your convenience, we accept all major credit cards, checks and cash.If your health insurance requires a referral for you to see a specialist, please contact your PCP and request a referral. A copy of the referral should be sent to our office prior to your appointment.Please have relevant medical records faxed to our office prior your appointment.ESTABLISHED PATIENT APPOINTMENT:Please provide our office with changes in your demographics and/or insurance.Consent forms are updated on a yearly basis.New insurance cards are required at the beginning of a new year or if you’ve changed insurance plans throughout a current year.MEDICAL RECORDS: Please allow at least 7-10 business days for processing. For you convenience, an authorization form to release medical records from our office is available on our website. The form can be faxed to our office at 928-778-0278 or emailed to frontdesk@ PRESCRIPTIONS: For a renewal request of a prescription, please contact your pharmacy first. Please allow 24-48 hours for your request to be processed. Please request all prescriptions during our normal business hours. Thank you for your attention to information provided above. We look forward to seeing you soon! 242 Whipple St., Suite 1Prescott, AZ 86301Phone: 928-708-9355 Fax: 928 -778-0278left466090First Name__________________________________ Last Name:_____________________________________Date of Birth: _______________________ Age: ______ Social Security Number: ____________________________Mailing Address: ___________________________________________________ Apt./Unit_______________City: ________________________________ State:_________________ Zip Code:_______________Home Phone: _______________________ Cell Phone: _______________________ Work Phone: __________________E-mail Address: _________________________________________________________Marital Status: ____ Single____Married____ Divorced____WidowOccupation: __________________________________________Emergency Contact________________________________ Phone Number:_____________________________00First Name__________________________________ Last Name:_____________________________________Date of Birth: _______________________ Age: ______ Social Security Number: ____________________________Mailing Address: ___________________________________________________ Apt./Unit_______________City: ________________________________ State:_________________ Zip Code:_______________Home Phone: _______________________ Cell Phone: _______________________ Work Phone: __________________E-mail Address: _________________________________________________________Marital Status: ____ Single____Married____ Divorced____WidowOccupation: __________________________________________Emergency Contact________________________________ Phone Number:_____________________________PATIENT INFORMATION190503761740Primary Health Plan Name:______________________________________ Group Number: _____________________ID Number: __________________________Effective Date: ________ Are you the main policy holder? ____Yes ____No If “No”, Please fill out : Name: ___________________________ DOB ___________________ SS #___________________Is a PCP referral required by your insurance company? ____ Yes ____NoSecondary Health Plan Name:______________________________________ Group Number: _____________________ID Number: __________________________Effective Date: ________ Are you the main policy holder? ____Yes ____No If “No”, Please fill out : Name: ___________________________ DOB ___________________ SS #___________________Is a PCP referral required by your insurance company? ____ Yes ____No00Primary Health Plan Name:______________________________________ Group Number: _____________________ID Number: __________________________Effective Date: ________ Are you the main policy holder? ____Yes ____No If “No”, Please fill out : Name: ___________________________ DOB ___________________ SS #___________________Is a PCP referral required by your insurance company? ____ Yes ____NoSecondary Health Plan Name:______________________________________ Group Number: _____________________ID Number: __________________________Effective Date: ________ Are you the main policy holder? ____Yes ____No If “No”, Please fill out : Name: ___________________________ DOB ___________________ SS #___________________Is a PCP referral required by your insurance company? ____ Yes ____NoINSURANCE INFORMATIONPlease note: We do not bill insurance for pellets, supplements, skin services and or weight loss products and services. These are considered non-billable products.SIGNATURE: _______________________________________ DATE: _______________________Personal Health InformationAt The Heart Shop, we are dedication to protecting your privacy. Therefore, please let us know what you prefer below.114300397510Name: ___________________________________________________ Date of Birth: ____________________I wish to be contacted in the following manner (Check all that Apply):____ Home Phone (List Home Phone Number) ___________________________ Is It okay to leave a detailed message? ____ Yes____No____ Cell Phone (List Cell Phone Number) _______________________________ Is it okay to leave a detailed message? _____ Yes _____No____ Work Phone(List Work Number ____________________________ Is it okay to leave a detailed message? ____ Yes ____ No ____ E- Mail (List E- Mail) __________________________________Please tell us who may receive information regarding your protected health information?Spouse/Significant Other Name: _______________________________ Phone Number: _______________________Children Name:_________________________________________ Phone Number: _________________________Children Name:_________________________________________ Phone Number: _________________________Children Name:_________________________________________ Phone Number: _________________________Other Person Name:_____________________________________ Phone Number: __________________________Please Note: Notes from your medical provider (Douglas Rothrock, MD) at the Heart Shop will be sent to your primary care physician/ or the referring physician UNLESS you instruct us to do otherwise. Please check one of the two choices below:____ I authorize you to send/ request my protected health information to/ from other healthcare providers who may be involved in my treatment directly or indirectly.___ DO NOT send my protected health information to my primary care physician.Patient Signature or Authorized Representative Signature______________________________________Printed Name:__________________________________ Date: ___________________________00Name: ___________________________________________________ Date of Birth: ____________________I wish to be contacted in the following manner (Check all that Apply):____ Home Phone (List Home Phone Number) ___________________________ Is It okay to leave a detailed message? ____ Yes____No____ Cell Phone (List Cell Phone Number) _______________________________ Is it okay to leave a detailed message? _____ Yes _____No____ Work Phone(List Work Number ____________________________ Is it okay to leave a detailed message? ____ Yes ____ No ____ E- Mail (List E- Mail) __________________________________Please tell us who may receive information regarding your protected health information?Spouse/Significant Other Name: _______________________________ Phone Number: _______________________Children Name:_________________________________________ Phone Number: _________________________Children Name:_________________________________________ Phone Number: _________________________Children Name:_________________________________________ Phone Number: _________________________Other Person Name:_____________________________________ Phone Number: __________________________Please Note: Notes from your medical provider (Douglas Rothrock, MD) at the Heart Shop will be sent to your primary care physician/ or the referring physician UNLESS you instruct us to do otherwise. Please check one of the two choices below:____ I authorize you to send/ request my protected health information to/ from other healthcare providers who may be involved in my treatment directly or indirectly.___ DO NOT send my protected health information to my primary care physician.Patient Signature or Authorized Representative Signature______________________________________Printed Name:__________________________________ Date: ___________________________ Thank you for your kind cooperationleft180975Financial/Office PoliciesThank you for choosing our practice! We are committed to the success of your medical treatmentand care. Please understand that payment of your bill is part of this treatment and care.For your convenience, we have answered a variety of commonly asked financial and office policy questions below. If you need further information about any of these policies, please contact our billing service. BILLING WRX4711 E FALCON DRIVE. SUITE 342 , MESA, AZ 85215PHONE:480-773-7322 FAX: 480-773-7022How May I Pay?We accept payment by cash, check, VISA, Mastercard, and Discover.What Is My Financial Responsibility for Services?You will be financially responsible for all copays and/or deductibles at the time of service, depending on the type of insurance plan you have. If you do not have insurance, payment in full is due at the time of service.What if my insurance doesn’t pay?It is your responsibility to know what is covered and what is not covered by your insurance plan. If your insurance chooses not to pay The Heart Shop for whatever reason or they choose to delay payment, YOU will be responsible for payment. If payment is not received from your insurance company within 60 days you will become responsible for the outstanding balance. SOME SERVICES OFFERED BY THE HEART SHOP ARE NOT VALID -BILLABLE SERVICES TO INSURANCE AND THEREFORE ARE ONLY CASH PAY SERVICES OR PRODUCTS . Examples of these non- billable services/products include but are not limited to: Hormone Therapy Pellets, Vitamins, Supplements, Healthy Skin 4 You skin services, and Weight Loss food products.What if my account becomes delinquent?Patients will be sent one statement at no charge. Any additional statements will incur a $10.00 statement generation fee.Delinquent accounts will be sent to our collection agency for recovery. If your account is sent to our collection agency, you will be responsible for all fees incurred from the collection agency.What if I write a check that is returned to your office unpaid?Our returned check fee is $30.00. If more than one returned check is received on your account, we will require that future payments be made by cash, cashier’s check or credit card. If you do not bring in payment for the check and returned check fee the check will be filed with the District Attorney’s office for collection. All fees incurred in the filing will be your responsibility as well.What if I need a form completed by the office or physician?Our physicians do not complete government or other types of forms on behalf of patients. Pleasecheck with your primary care provider for the completion of forms.What if I need a copy of my medical records?We require a signed medical records release before processing any records requests. As a courtesy to our patients, we will provide you with up to two (2) copies per year of your complete medical chart. If additional requests are made by the patient, all additional requests within that year for medical records will incur a fee. There will be a fee of $25.00 for the first 20 pages and 50 cents for each additional page. These will be processed within 15 business days. 00Financial/Office PoliciesThank you for choosing our practice! We are committed to the success of your medical treatmentand care. Please understand that payment of your bill is part of this treatment and care.For your convenience, we have answered a variety of commonly asked financial and office policy questions below. If you need further information about any of these policies, please contact our billing service. BILLING WRX4711 E FALCON DRIVE. SUITE 342 , MESA, AZ 85215PHONE:480-773-7322 FAX: 480-773-7022How May I Pay?We accept payment by cash, check, VISA, Mastercard, and Discover.What Is My Financial Responsibility for Services?You will be financially responsible for all copays and/or deductibles at the time of service, depending on the type of insurance plan you have. If you do not have insurance, payment in full is due at the time of service.What if my insurance doesn’t pay?It is your responsibility to know what is covered and what is not covered by your insurance plan. If your insurance chooses not to pay The Heart Shop for whatever reason or they choose to delay payment, YOU will be responsible for payment. If payment is not received from your insurance company within 60 days you will become responsible for the outstanding balance. SOME SERVICES OFFERED BY THE HEART SHOP ARE NOT VALID -BILLABLE SERVICES TO INSURANCE AND THEREFORE ARE ONLY CASH PAY SERVICES OR PRODUCTS . Examples of these non- billable services/products include but are not limited to: Hormone Therapy Pellets, Vitamins, Supplements, Healthy Skin 4 You skin services, and Weight Loss food products.What if my account becomes delinquent?Patients will be sent one statement at no charge. Any additional statements will incur a $10.00 statement generation fee.Delinquent accounts will be sent to our collection agency for recovery. If your account is sent to our collection agency, you will be responsible for all fees incurred from the collection agency.What if I write a check that is returned to your office unpaid?Our returned check fee is $30.00. If more than one returned check is received on your account, we will require that future payments be made by cash, cashier’s check or credit card. If you do not bring in payment for the check and returned check fee the check will be filed with the District Attorney’s office for collection. All fees incurred in the filing will be your responsibility as well.What if I need a form completed by the office or physician?Our physicians do not complete government or other types of forms on behalf of patients. Pleasecheck with your primary care provider for the completion of forms.What if I need a copy of my medical records?We require a signed medical records release before processing any records requests. As a courtesy to our patients, we will provide you with up to two (2) copies per year of your complete medical chart. If additional requests are made by the patient, all additional requests within that year for medical records will incur a fee. There will be a fee of $25.00 for the first 20 pages and 50 cents for each additional page. These will be processed within 15 business days. -190500-161290left0What happens if I am late to my appointment or I fail to show up?We recognize that patients may need to cancel or change an appointment but request that theyprovide at least 24 hours notice so we may offer their appointed time to another patient.If you arrive over 10 minutes late to your appointment you may be asked to reschedule as this delay affects not only the physician, but other patients that are scheduled after you.For office visits, depending on the circumstances, there may be a $25.00 charge for NO SHOWpatients or patients who cancel their appointment less than 24 hours in advance, as theseappointment times could have been given to a patient(s) in need.If neglecting to show up to your appointment begins to be a pattern, the physician may discharge you from the practice.What if I need a prescription refilled?If you are calling for a prescription refill you must contact your pharmacy unless the prescription is one which, by law, must be picked up from our office. Only prescription refill requests from a pharmacy will be honored. You must allow at least forty-eight (48) hours for all refill requests to be processed.What if My Child Needs to See the Physician?A parent or legal guardian must accompany patients who are minors on the patient’s firstvisit. This accompanying adult is responsible for payment of the account, according to the policyoutlined on the previous pages.Please remember that when you receive billing statements you have already received quality care from our physicians and your insurance billing paperwork has been completed by us. We would then ask that you pay promptly upon receiving your statement.Please feel free to contact our business office if you have any questions regarding your statement or insurance. We are happy to answer your questions or to provide additional information.Notice to all Medicare PatientsThe Heart Shop, LLC is a participating provider with Medicare. The Heart Shop has agreed toaccept assignment on all Medicare claims. This means that they will accept Medicare's approvedamount (which is the 80% that Medicare pays plus the 20% patient co-insurance) as payment in full for all covered services.The patient or the patient's secondary insurer is still responsible for the 20% co-insurance and annual deductible, but the physician will not bill the patient for amounts in excess of the Medicare allowance.By my signature below, please note that I understand the above and I authorize my Medicare benefits to be paid directly to The Heart Shop for services provided.00What happens if I am late to my appointment or I fail to show up?We recognize that patients may need to cancel or change an appointment but request that theyprovide at least 24 hours notice so we may offer their appointed time to another patient.If you arrive over 10 minutes late to your appointment you may be asked to reschedule as this delay affects not only the physician, but other patients that are scheduled after you.For office visits, depending on the circumstances, there may be a $25.00 charge for NO SHOWpatients or patients who cancel their appointment less than 24 hours in advance, as theseappointment times could have been given to a patient(s) in need.If neglecting to show up to your appointment begins to be a pattern, the physician may discharge you from the practice.What if I need a prescription refilled?If you are calling for a prescription refill you must contact your pharmacy unless the prescription is one which, by law, must be picked up from our office. Only prescription refill requests from a pharmacy will be honored. You must allow at least forty-eight (48) hours for all refill requests to be processed.What if My Child Needs to See the Physician?A parent or legal guardian must accompany patients who are minors on the patient’s firstvisit. This accompanying adult is responsible for payment of the account, according to the policyoutlined on the previous pages.Please remember that when you receive billing statements you have already received quality care from our physicians and your insurance billing paperwork has been completed by us. We would then ask that you pay promptly upon receiving your statement.Please feel free to contact our business office if you have any questions regarding your statement or insurance. We are happy to answer your questions or to provide additional information.Notice to all Medicare PatientsThe Heart Shop, LLC is a participating provider with Medicare. The Heart Shop has agreed toaccept assignment on all Medicare claims. This means that they will accept Medicare's approvedamount (which is the 80% that Medicare pays plus the 20% patient co-insurance) as payment in full for all covered services.The patient or the patient's secondary insurer is still responsible for the 20% co-insurance and annual deductible, but the physician will not bill the patient for amounts in excess of the Medicare allowance.By my signature below, please note that I understand the above and I authorize my Medicare benefits to be paid directly to The Heart Shop for services provided.PATIENT ACKNOWLEDGEMENTleft181610PATIENT ACKNOWLEDGEMENTI have read, understand, and agree to the above Financial Policy. I understand that chargesnot covered by my insurance company, as well as applicable copayments and deductibles,are my responsibility. Further, I authorize my insurance benefits be paid directly to The Heart Shop.______________________________________________PLEASE PRINT YOUR NAME__________________________________________________ _______________PATIENT SIGNATURE or AUTHORIZED REPRESENTATIVE DATE00PATIENT ACKNOWLEDGEMENTI have read, understand, and agree to the above Financial Policy. I understand that chargesnot covered by my insurance company, as well as applicable copayments and deductibles,are my responsibility. Further, I authorize my insurance benefits be paid directly to The Heart Shop.______________________________________________PLEASE PRINT YOUR NAME__________________________________________________ _______________PATIENT SIGNATURE or AUTHORIZED REPRESENTATIVE DATE-180975-94615-2095503161029Social History:Marital Status: ____ Single____Married____ Divorced____WidowHow many children do you have? ________ How old are they? ________Do you exercise? ___Yes___No If yes, how often ? __________________________Do you smoke? ___ Yes___No If yes, how many per day? ________Do you consume alcoholic beverages? ___ Yes ___No? If yes, how many beverages a week? _______Do you consume caffeine? ___Yes____No If yes, how many beverages/food items a day? _______Current weight:____________Minimum adult weight:_______________ Maximum adult weight:______________FOLLOWING QUESTIONS ARE ONLY FOR PATIENTS INTERESTED IN HORMONE THERAPY TREATMENT. All others skip to next page.Are you sexually active? ____ Yes____No If no, do you want to be sexually active? _____ Yes ______No Has your sex suffered? _____ Yes _____NoAre you able to orgasm? _____Yes______NoHave you used steroids in the past for athletic purposes? _____ Yes______NoFor Males : I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, that I will produce less testosterone from my testicles and if I stop replacement, I may experience a temporary decrease in my testosterone production. Testosterone Pellets should be completely out of your system in 12 months. By beginning treatment, I accept all the risks of therapy stated herein and future risks that might be reported. I understand that higher than normal physiological levels may be reached to create the necessary hormonal balance.Print Name:___________________________ Signature:________________________________ Date:________________00Social History:Marital Status: ____ Single____Married____ Divorced____WidowHow many children do you have? ________ How old are they? ________Do you exercise? ___Yes___No If yes, how often ? __________________________Do you smoke? ___ Yes___No If yes, how many per day? ________Do you consume alcoholic beverages? ___ Yes ___No? If yes, how many beverages a week? _______Do you consume caffeine? ___Yes____No If yes, how many beverages/food items a day? _______Current weight:____________Minimum adult weight:_______________ Maximum adult weight:______________FOLLOWING QUESTIONS ARE ONLY FOR PATIENTS INTERESTED IN HORMONE THERAPY TREATMENT. All others skip to next page.Are you sexually active? ____ Yes____No If no, do you want to be sexually active? _____ Yes ______No Has your sex suffered? _____ Yes _____NoAre you able to orgasm? _____Yes______NoHave you used steroids in the past for athletic purposes? _____ Yes______NoFor Males : I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, that I will produce less testosterone from my testicles and if I stop replacement, I may experience a temporary decrease in my testosterone production. Testosterone Pellets should be completely out of your system in 12 months. By beginning treatment, I accept all the risks of therapy stated herein and future risks that might be reported. I understand that higher than normal physiological levels may be reached to create the necessary hormonal balance.Print Name:___________________________ Signature:________________________________ Date:________________-209550361950Physician Information:Who is your primary care physician?_____________________________________ Phone Number:____________________Please list any physicians you see and their specialty (refer to medical information for list of disorders):Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________00Physician Information:Who is your primary care physician?_____________________________________ Phone Number:____________________Please list any physicians you see and their specialty (refer to medical information for list of disorders):Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Dr._________________________ Phone #:________________________ Specialty:_____________________________Patient Since:____________ (MM/YY) Last Visit:_____________________________________Health Profile PG. 1 NAME:_________________________________ DOB _____________ left7724140DIGESTIVE FUNCTIONDo you have any of the following conditions: (check all that apply)___ Acid Reflux ____ Celiac Disease ____Gluten Intolerance ___ Heartburn ___ Gastric Ulcer___ History of Bariatric Surgery If so, what type of bariatric surgery?______________________00DIGESTIVE FUNCTIONDo you have any of the following conditions: (check all that apply)___ Acid Reflux ____ Celiac Disease ____Gluten Intolerance ___ Heartburn ___ Gastric Ulcer___ History of Bariatric Surgery If so, what type of bariatric surgery?______________________left4991100COLON FUNCTIONDo you have any of the following conditions: (check all that apply)___ Constipation ___ Chron’s Disease___ Diverticulitis___ Irritable Bowel Syndrome___ Ulcerative Colitis___ DiarrheaIf yes to any of theses conditions, please give dates of events, for multiple events please specify:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________00COLON FUNCTIONDo you have any of the following conditions: (check all that apply)___ Constipation ___ Chron’s Disease___ Diverticulitis___ Irritable Bowel Syndrome___ Ulcerative Colitis___ DiarrheaIf yes to any of theses conditions, please give dates of events, for multiple events please specify:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________left3448050LIVER FUNCTIONHave you ever had any liver conditions (HIV, Hepatitis etc.)? ____ Yes______No Date: _______________If yes, please list:___________________________________________________________________________________Have you ever had a gallstone incident? _____Yes_____No00LIVER FUNCTIONHave you ever had any liver conditions (HIV, Hepatitis etc.)? ____ Yes______No Date: _______________If yes, please list:___________________________________________________________________________________Have you ever had a gallstone incident? _____Yes_____Noleft466725DIABETESDo you have diabetes? ____ Yes No_____ If no, please skip to next sectionMark which type of dibetes :___Type I Insulin-dependent (insulin injections only)___Type II Non-insulin-dependent (diabetic pills)___ Type II Insulin-dependent (diabetic pills and insuling)Is your blood sugar level monitored? ____Yes_____No If so, how often?____________ If so, by whom? ____Myself ____Physician____Other – please specify:___________________Do you tend to be hypoglycemic? _____Yes _____No00DIABETESDo you have diabetes? ____ Yes No_____ If no, please skip to next sectionMark which type of dibetes :___Type I Insulin-dependent (insulin injections only)___Type II Non-insulin-dependent (diabetic pills)___ Type II Insulin-dependent (diabetic pills and insuling)Is your blood sugar level monitored? ____Yes_____No If so, how often?____________ If so, by whom? ____Myself ____Physician____Other – please specify:___________________Do you tend to be hypoglycemic? _____Yes _____No Health Profile PG. 2 NAME:_________________________________ DOB _____________Health Profile PG. 3 NAME:_________________________________ DOB _____________ -666755895975NEUROLOGICAL/ EMOTIONAL FUNCTIONDo you have any of the following conditions: (check all that apply)___ Alzheimer’s disease___ Anorexia (History of)___ Anxiety ___ Bipolar Disorder___ Bulimia (History of)___ Depression___ Epilepsy (NPA)___ Panic Attacks___ Parkinson’s Disease___ SchizophreniaAny other Psychiatric Disorders? _________________________________________________________________________________________________00NEUROLOGICAL/ EMOTIONAL FUNCTIONDo you have any of the following conditions: (check all that apply)___ Alzheimer’s disease___ Anorexia (History of)___ Anxiety ___ Bipolar Disorder___ Bulimia (History of)___ Depression___ Epilepsy (NPA)___ Panic Attacks___ Parkinson’s Disease___ SchizophreniaAny other Psychiatric Disorders? _________________________________________________________________________________________________-571502876550KIDNEY FUNCTIONHave you ever had any of the following conditions: (check all that apply) ___ Kidney Disease (NPA)___Trouble passing unire or take Flomax or Avodart___ Kidney Stones___ Kidney Transplant (NPA)___ Gout Do you presently have gout?___ Yes___ No If yes, since when?____________________ If yes, what medication has been prescribed? ___________________________If yes to any of these events, please give dates of events: For multiple vents please specify:_____________________________________________________________________________________________________________________________________________________________________________________________________00KIDNEY FUNCTIONHave you ever had any of the following conditions: (check all that apply) ___ Kidney Disease (NPA)___Trouble passing unire or take Flomax or Avodart___ Kidney Stones___ Kidney Transplant (NPA)___ Gout Do you presently have gout?___ Yes___ No If yes, since when?____________________ If yes, what medication has been prescribed? ___________________________If yes to any of these events, please give dates of events: For multiple vents please specify:_____________________________________________________________________________________________________________________________________________________________________________________________________-95250504825ENDOCRINE FUNCTIONDo you have thyroid problems? ____Yes ____No If so, please specify: _________________________________Do you have parathyroid problems? ____Yes ____No If so, please specify:_________________________________Do you have adrenal gland problems? ____Yes ____No If so, please specify: _________________________________Have you been told you have Metabolic Syndrome? _____ Yes _____NoDo you have Hashimoto’s Thyroiditis? _____Yes_____NoAre you currently on Thyroid Medication? _____Yes _____No If yes, what medication? _____________________00ENDOCRINE FUNCTIONDo you have thyroid problems? ____Yes ____No If so, please specify: _________________________________Do you have parathyroid problems? ____Yes ____No If so, please specify:_________________________________Do you have adrenal gland problems? ____Yes ____No If so, please specify: _________________________________Have you been told you have Metabolic Syndrome? _____ Yes _____NoDo you have Hashimoto’s Thyroiditis? _____Yes_____NoAre you currently on Thyroid Medication? _____Yes _____No If yes, what medication? _____________________Health Profile PG. 4 NAME:_________________________________ DOB _____________ 571505657850CANCERDo you have cancer? (NPC) ___ Yes___ No If so, what type?____________________________________Have you ever had cancer? ___ Yes___ No If so, what type?____________________________________Is your cancer in remission? (NPC) ___ Yes___ No If so, when?________________________ (MM/YY)Any of the following cancers? (Mark all that apply)___ Testicular or prostate cancer___ Elevated PSA___ Prostate enlargement___ Uterine Cancer___ Ovarian Cancer___ Breast Cancer ( ) Estrogen Receptive ( ) Progesterone Receptive ( ) Genetics00CANCERDo you have cancer? (NPC) ___ Yes___ No If so, what type?____________________________________Have you ever had cancer? ___ Yes___ No If so, what type?____________________________________Is your cancer in remission? (NPC) ___ Yes___ No If so, when?________________________ (MM/YY)Any of the following cancers? (Mark all that apply)___ Testicular or prostate cancer___ Elevated PSA___ Prostate enlargement___ Uterine Cancer___ Ovarian Cancer___ Breast Cancer ( ) Estrogen Receptive ( ) Progesterone Receptive ( ) Genetics38100295275OVARIAN / BREAST/ MALE FUNCTION ( Females, please fill out pink and black. Males, please fill out blue and black)Do you have any of the following conditions:___ Amenorrhea___ Fibrocystic Breasts___ Heavy Periods___ Hysterectomy only___Oophorectomy Removal of Ovaries___ Hysterectomy with removal of ovaries___ Irregular Periods___ Uterine Fibroma___ Vasectomy___ History of Leiomyoma or Endometrial Polyps___ Tubal Ligation ___ PCOS___ Hot FlashesDate of last menstrual cycle: _________________________Are you taking oral contraceptive pills? ___ Yes___ NoAre you pregnant? ___ Yes___ NoAre you breastfeeding? ___ Yes___ NoPREVENTATIVE MEDICAL CARE (please check all statements that apply)___ Medical Physical/ GYN Exam in the last 12 months.___ Mammogram in the last 12 months.___ Bone Density in the last 12 months.___ Pelvic Ultrasound in the last 12 months. 00OVARIAN / BREAST/ MALE FUNCTION ( Females, please fill out pink and black. Males, please fill out blue and black)Do you have any of the following conditions:___ Amenorrhea___ Fibrocystic Breasts___ Heavy Periods___ Hysterectomy only___Oophorectomy Removal of Ovaries___ Hysterectomy with removal of ovaries___ Irregular Periods___ Uterine Fibroma___ Vasectomy___ History of Leiomyoma or Endometrial Polyps___ Tubal Ligation ___ PCOS___ Hot FlashesDate of last menstrual cycle: _________________________Are you taking oral contraceptive pills? ___ Yes___ NoAre you pregnant? ___ Yes___ NoAre you breastfeeding? ___ Yes___ NoPREVENTATIVE MEDICAL CARE (please check all statements that apply)___ Medical Physical/ GYN Exam in the last 12 months.___ Mammogram in the last 12 months.___ Bone Density in the last 12 months.___ Pelvic Ultrasound in the last 12 months. left2081530CARDIOVASCULARHave you ever had any of the following conditions? (Check all that apply)___ Arrhythmia___ Hemochromatosis___ Heart Attack___ Blood Clot___ Coronary Artery Disease (CAD) ___Heart Valve Problem___ Hyperkalemia (High Potassium)___ Heart Valve Replacement (porcine/mechanical)___ Pulmonary Embolism___ Hypokalemia (Low Potassium)___ Hypertension (High Blood Pressure)___ Hyperlipidemia (High Cholesterol/ Triglycerides) ___ Stroke or Transient Ischemic Attack (TIA)___ Congestive Heart Failure ___ Abdominal Aneurysm___ Shortness of Breath___ Pulmonary Hypertension___ Enlarged Heart___ Clogged ArteriesHave you ever had an abnormal EKG? ____ Yes _____ NoHave you ever had an abnormal stress test? ____ Yes_____ No Have you ever had a Cardiac Catherization? ____ Yes_____ No If yes, was it normal? ___ Yes___ NoWhen was it done? _________________________ (MM/YY) Name of surgeon or facility:_______________________Have you ever had heart stents? ___ Yes___ No If yes, please bring stent ID card to the office.Have you ever had a Heart Valve Replaced? ___ Yes___No If yes, please bring valve ID Card to the office.Do you have a Pacemaker? ___ Yes___ No If yes, please bring your device ID card to the office.When was it inserted? ______________________ (MM/YY) Name of surgeon or facility:________________________Have you had Bypass Surgery? ___ Yes ___ No When was it done? ________________________ (MM/YY) Name of surgeon or facility: ________________________ Other Cardiac Surgery:________________________ Date:___________________ Name of surgeon or facility:______________________00CARDIOVASCULARHave you ever had any of the following conditions? (Check all that apply)___ Arrhythmia___ Hemochromatosis___ Heart Attack___ Blood Clot___ Coronary Artery Disease (CAD) ___Heart Valve Problem___ Hyperkalemia (High Potassium)___ Heart Valve Replacement (porcine/mechanical)___ Pulmonary Embolism___ Hypokalemia (Low Potassium)___ Hypertension (High Blood Pressure)___ Hyperlipidemia (High Cholesterol/ Triglycerides) ___ Stroke or Transient Ischemic Attack (TIA)___ Congestive Heart Failure ___ Abdominal Aneurysm___ Shortness of Breath___ Pulmonary Hypertension___ Enlarged Heart___ Clogged ArteriesHave you ever had an abnormal EKG? ____ Yes _____ NoHave you ever had an abnormal stress test? ____ Yes_____ No Have you ever had a Cardiac Catherization? ____ Yes_____ No If yes, was it normal? ___ Yes___ NoWhen was it done? _________________________ (MM/YY) Name of surgeon or facility:_______________________Have you ever had heart stents? ___ Yes___ No If yes, please bring stent ID card to the office.Have you ever had a Heart Valve Replaced? ___ Yes___No If yes, please bring valve ID Card to the office.Do you have a Pacemaker? ___ Yes___ No If yes, please bring your device ID card to the office.When was it inserted? ______________________ (MM/YY) Name of surgeon or facility:________________________Have you had Bypass Surgery? ___ Yes ___ No When was it done? ________________________ (MM/YY) Name of surgeon or facility: ________________________ Other Cardiac Surgery:________________________ Date:___________________ Name of surgeon or facility:______________________Health Profile PG. 5 NAME:_________________________________ DOB _____________ 47625466725INFLAMMATORY CONDITIONSDo you have any of the following conditions: (check all that apply)___ Chronic Fatigue Syndrome___Fibromyalgia___ Lupus___ Osteoarthritis___ Multiple Sclerosis___Psoriasis ___ Rheumatoid___ Migraines___ Arthritis _______________Other00INFLAMMATORY CONDITIONSDo you have any of the following conditions: (check all that apply)___ Chronic Fatigue Syndrome___Fibromyalgia___ Lupus___ Osteoarthritis___ Multiple Sclerosis___Psoriasis ___ Rheumatoid___ Migraines___ Arthritis _______________Other47625457200CARDIOVASCULAR continuedFAMILY MEDICAL HISTORYIf you were adopted or do not know your family history, please check here: ____Please write in the space provided below any BLOOD RELATIVES that had any of the following: Abdominal Aneurysm _________________Heart Attack_________________________Blood Clot in Lung(s)__________________Heart Murmur _______________________Bypass Surgery ______________________Heart Valve Replacement ______________Cardiac Arrest _______________________High Blood Pressure __________________Clogged Arteries _____________________Irregular Heart Beat __________________Congestive Heart Failure_______________Pacemaker _________________________Diabetes____________________________Poor Circulation _____________________Enlarged Heart _______________________Sudden Death _______________________Problems with Anesthesia _________________________________Are you presently or have you recently experienced any of the following: (check all that apply)___ Chest pain/ pressure/ tightnessWhen?________________ What makes the pain better?_________________What makes the pain worse?____________________________ Shortness of Breath When? ___________________What makes the SOB better?____________________What makes the SOB worse? ____________________________ Visual Disturbances? When?__________________ What makes the visual disturbance better?_______________________ What makes the visual disturbance worse?____________________________________ Lightheadedness/Dizziness When?_______________________ What makes it better?_________________What makes it worse? ________________________________00CARDIOVASCULAR continuedFAMILY MEDICAL HISTORYIf you were adopted or do not know your family history, please check here: ____Please write in the space provided below any BLOOD RELATIVES that had any of the following: Abdominal Aneurysm _________________Heart Attack_________________________Blood Clot in Lung(s)__________________Heart Murmur _______________________Bypass Surgery ______________________Heart Valve Replacement ______________Cardiac Arrest _______________________High Blood Pressure __________________Clogged Arteries _____________________Irregular Heart Beat __________________Congestive Heart Failure_______________Pacemaker _________________________Diabetes____________________________Poor Circulation _____________________Enlarged Heart _______________________Sudden Death _______________________Problems with Anesthesia _________________________________Are you presently or have you recently experienced any of the following: (check all that apply)___ Chest pain/ pressure/ tightnessWhen?________________ What makes the pain better?_________________What makes the pain worse?____________________________ Shortness of Breath When? ___________________What makes the SOB better?____________________What makes the SOB worse? ____________________________ Visual Disturbances? When?__________________ What makes the visual disturbance better?_______________________ What makes the visual disturbance worse?____________________________________ Lightheadedness/Dizziness When?_______________________ What makes it better?_________________What makes it worse? ________________________________381006911975GENERALDo you have any other health problems? ___Yes___ No If so, please specify:_________________________________________________________________________________Any surgeries, that have not already been listed? ____ Yes ___ NoIf so, please specify:_________________________________________________________________________________Do you accept Blood Transfusions? ____ Yes___ NoDo you have a Medical Power of Attorney or Living Will? ___ Yes ___ No If so, please bring a copy to the office.00GENERALDo you have any other health problems? ___Yes___ No If so, please specify:_________________________________________________________________________________Any surgeries, that have not already been listed? ____ Yes ___ NoIf so, please specify:_________________________________________________________________________________Do you accept Blood Transfusions? ____ Yes___ NoDo you have a Medical Power of Attorney or Living Will? ___ Yes ___ No If so, please bring a copy to the office.Health Profile PG. 6 NAME:_________________________________ DOB _____________ Health Profile PG. 7 NAME:_________________________________ DOB _____________ Medication and Supplements ListPlease list all prescription medications and supplements you are currently taking.If you need more space, feel free to write on the back of this sheet, or bring a signed copy of your CURRENT medication list with all the info below.Name of MedicationMilligrams *per capsuleNumber of capsules per dayNumber of doses per dayPrescribing doctorReason for taking this medicationVitamin X500 mg11x a dayDr. John DoeOmega 3Signature: ___________________________________Date:_________________________Health Profile PG. 8 NAME:_________________________________ DOB _____________ right474345MEDICATION ALLERGIESARE YOU ALLERGIC TO ANY MEDICATIONS? ____ Yes____ NoIf so, please list the medications you are allergic to below:Medication:What Reaction does it cause?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do yo have any other allegies or sensitivities? _____ Yes _____ NoIf so, please specify: ___________________________________________________________________________Have you ever had any issues with anesthesia? ____ Yes_____ NoIf so, please specify:___________________________________________________________________________00MEDICATION ALLERGIESARE YOU ALLERGIC TO ANY MEDICATIONS? ____ Yes____ NoIf so, please list the medications you are allergic to below:Medication:What Reaction does it cause?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do yo have any other allegies or sensitivities? _____ Yes _____ NoIf so, please specify: ___________________________________________________________________________Have you ever had any issues with anesthesia? ____ Yes_____ NoIf so, please specify:___________________________________________________________________________Signature:____________________________________________ Date:_________________________ ................
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