New Patient Form Incoming New Patient Information "*" indicates required fields Step 1 of 5 20% Male Patient InformationYour Name* hipaa_forms_first_name hipaa_forms_last_name Todays Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your AgeDate of Last Physical Exam*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920D.L. Number - No Dashes or Periods* State Abv. Date of Birth* Month Day Year Marital Status*MarriedSingleDivorcedWidowedSeparatedAddress* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email Address* Enter Email Confirm Email Your Phone*Mobile Phone*Best Time To Call You*MorningsEarly AfternoonLate AfternoonEarly EveningWeekendsPrimary Care Doctor (PCP)* First Last Phone Number*Occupation* Employer* Work Number*Emergency Contact* First Last Phone Number*Referred By:*Choose all that apply. Friend Family Google Search Social Media Newsletter Medical Professional Website Other Responsible Party*Financially Responsible Person First Last Phone Number*Primary NumberRelationship to Patient* Date of Birth* Month Day Year Address* Same as previous Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Signature* Terms and Conditions*Terms and conditions placeholder. I agree to the terms and conditions. Male HRT Personal HistoryGeneral:*Check all that apply Diabetes High Cholesterol Family history of cancer Personal history of cancer Weight Loss None of the Above Select AllCardiovascular:*Check all that apply Chest Pain Heart Failure Heart Murmur Vascular Disease Blood Clots Fainting Lower Extremity Edema Hypertension (High BP) None of the Above Select AllGastrointestinal:*Check all that apply Lactose Intolerance Gallbaldder Gall Stones Diarrhea Constipation None of the Above Select AllGenitourinary:*Check all that apply Prostate cancer- personal or family Overactive bladder/frequent urination Painful urination Decreased force of urination On/off urine flow Incomplete emptying of bladder Prostate Enlargement/BPH Burning during urination Blood in urine History of kidney or bladder Infection Kidney or bladder infection in the last 12 months Liver disease None of the Above Select AllPsychiatric:*Check all that apply History of Depression Medications or Prescriptions None of the Above List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers:*List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers:Drug NameDosageFrequencyTaken ForNone Add RemoveAllergies:*Check all that apply No Known Allergies List of Allergies and Reaction Allergies List:*List any allergies and reactions.Allergic to:Reaction: Add RemoveSurgeries* Yes No Surgeries List:*List any surgeries & reason for.YearSurgery:Reason for: Add RemoveExercise:*Check all that apply Sedentary (No exercise) Mild exercise Occasional vigorous exercise Regular vigorous exercise None Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week, etc.):Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week, etc.):Alcohol:*Do you consume Alcohol in any form? Yes No Number of drinks per week:Estimate # of drinks per week regardless of type.Tobacco:* Yes No Cigarettes Cigars Chew Quantity Illicit Drugs:* Yes No Patient Acknowledgement of Receipt of Notice of Privacy PracticesI acknowledge that I have reviewed the Notice of Privacy Practices of Peak Male Institute.Please check ONE of the following:* I do not request a copy of the Notice of Privacy Practices at this time. I acknowledge that I can access Notice of Privacy Practices online anytime at LINK. I wish to receive a paper copy of the Notice of Privacy Practices. I wish to receive an electronic copy of the Notice of Privacy Practices. Please read and initial ALL below:* I acknowledge that it is the policy of Peak Male Institute (DBA-PMI) to leave reminder messages electronically or with another person in my home. I may also request an alternative means of communication (within reason) in writing. I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Compliance Officer, David Verizzo (clinic@peakmaleinstitute.com ), about my concerns. Select AllPatient Printed Name* Signature of Patient/Guardian* Date* MM slash DD slash YYYY Agreements and Authorizations: Consent to Release of InformationYou authorize Peak Male Institute/Men’s Complete Health, LLC to release to government agencies, insurance companies, or other third-party payers and their agents, and its collection representatives and attorneys, the following “Patient Information”: medical history, diagnoses and procedures performed, course of treatment, plan of care, prognosis, supplies and/or such other information that may be requested for the purpose of determining eligibility and availability of Patient’s benefits, obtaining authorization/payment for Patient’s health care services, or billing and collection of amounts due to Peak Male Institute/Men’s Complete Health, LLC for services rendered. In the case of Patient Information released for purposes of payment of Patient Charges, this authorization shall be valid only for the period of time necessary to process payment claims. You further authorize any individual health care professional, including treating physician(s), to provide Peak Male Institute/Men’s Complete Health, LLC or its designee with Patient Information for quality assurance and, or risk management purposes. Finally, in the event that the Patient’s employer, or an insurance company representing such employer, request Patient Information relating to healthcare services provided for worker’s compensation injuries, it is understood and agreed that Peak Male Institute/Men’s Complete Health, LLC is required, under Florida law, to release copies of such information to such employer or insurance company without the authorization of Patient or Patient’s representative.Patient Printed Name* Signature of Patient/Guardian* Date* MM slash DD slash YYYY SYMPTOMS OF LOW TESTOSTERONE LEVELSDecreased concentration* Yes No Difficulty learning new things* Yes No Moodiness* Yes No Depression* Yes No Increasing fatigue* Yes No Decreasing energy* Yes No Daytime sleepiness* Yes No Poor sleep habits* Yes No Erectile dysfunction* Yes No I have had testosterone checked previously* Yes No I have used testosterone previously* Yes No If Yes:Date(s)Type:Usage: Add RemoveSection BreakPatient Printed Name* Signature of Patient/Guardian* Date* MM slash DD slash YYYY ADAM questionnaire about symptoms of low testosterone(Androgen Deficiency in Aging Male) This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms.Do you have a decrease in libido (sex drive)?* Yes No Do you have a lack of energy?* Yes No Do you have a lack of energy?* Yes No Have you lost height?* Yes No Have you noticed a decreased “enjoyment of life” ?* Yes No Are you sad and/or grumpy?* Yes No Are your erections less strong?* Yes No Have you noticed a recent deterioration in your ability to play sports?* Yes No Are you falling asleep after dinner?* Yes No Has there been a recent deterioration in your work performance?* Yes No Male HRT or TRT Replacement Information & ConsentIt is important to understand that medicine is an inexact science. Although we will carry out your treatment carefully, results may vary in their degree of success. It is quite natural for a patient undergoing Testosterone and or Hormone Replacement Therapy to want to know that everything will turn out all right. While most of the time this is the case, it is very important for you to be aware of the potential risks, as well as the benefits, expected from the treatment when deciding on whether to begin Hormone Replacement Therapy. You should also be aware of the alternatives to Testosterone and or Hormone Replacement Therapy, including not receiving the treatment. It is important that you consider the information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take some time to weigh your options or consult another health care provider. Please review the following statements, which discuss informed consent. Any questions that you may have should be brought to our attention. Your clinical provider will attempt to answer all your questions to your satisfaction.Directions:Read and Check each box beside every statement below.By Checking each box I confirm that I have read each statement, understand and agree.* This is my consent for Peak Male Institute/Men’s Complete Health, LLC including any physician or nurse or other health care provider or any other person who works with the company, to begin my treatment for Testosterone Replacement Therapy, should I decide to move forward with care. I fully understand that occasionally there are complications with this treatment such as Acne, Breast Enlargement, Mood Swings, as well as the following (#3-#7). Extra fluid in the body- This can cause problems for patients with heart, kidney or liver disease. Sleep disturbance- This is called sleep apnea and is more likely to occur in those with lung issues Prostate enlargement- this may cause problems with urinating. Changes in cholesterol levels, red blood cell levels, PSA levels, liver function enzymes, and other hormone levels which will be monitored with periodic blood tests. I understand that I will have periodic blood tests to monitor my blood levels. I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse. I understand that I will have an opportunity to discuss with Peak Male Institute/Men’s Complete Health, LLC and its medical practitioners my complete past medical and health history including any serious problems and/or injuries. At that time I will have the opportunity to ask questions about the care provided. I understand that the physical exam by Peak Male Institute/Men’s Complete Health, LLC does NOT replace a full physical exam by a personal physician. I agree to have my personal Physician perform a yearly full physical exam including a digital rectal exam, lipid profile, cholesterol levels and a comprehensive metabolic panel. If I do not have a personal physician, Peak Male Institute/Men’s Complete Health, LLC will assist in locating one for me. I understand that prolonged HRT therapy may reduce ejaculate volume and reduce sperm count, possibly affecting fertility. Patient SignaturesBy adding my signature below I confirm and agree that while a patient of Peak Male Institute (DBA-PMI) I will not take any type of anabolic steroids, testosterone gels, hormone “boosters,” pro- hormones or any additional testosterone supplementation not provided by Peak Male Institute (DBA-PMI) during my treatment plan. At any time, if use of these items is discovered, I understand I may be discharged as a patient of Peak Male Institute (DBA-PMI).Patient Printed Name* Signature of Patient/Guardian* Date* MM slash DD slash YYYY Witness Printed Name* Signature of Witness* Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
