Intake form

New Patient Intake

General Information

Participant: Please write legibly as this information is used to complete your patient chart.

First Name

Middle Name

Last Name

Date of Birth(mm/dd/yy):

Height:

Weight:

Marital Status:

Single

Married

Divorced

Widowed

Gender:

Male

Female

Current Home Address:

City

State

Zip Code

Phone Number

Email:

I authorize contact from this office to confirm my appointments, treatments, and billing information by means:

Cell Phone

Home Phone

Text message

All of the above

How did you hear about Optimal Medicine?

Family Physician and/or Primary Health Care Provider:

Doctor/Other:

Phone:

Address

City

State

Zip Code

May we send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?

Yes

Are you currently on any type of hormone replacement therapy:

Yes

What is (are) your purpose (s) for participation in this HRT Program, please describe your goals, area(s) of concern, and issues that you would like addressed.

Please list ALL current or past hormone replacement or testosterone therapy medically supervised or otherwise:

List any medical problems that other doctors have diagnosed:

Medical History: Check all that apply

Has a doctor ever said your blood pressure was too high?

Do you ever have pain in your chest or heart?

Are you often bothered by a thumping of the heart?

Does your heart often race?

Do you ever notice extra heartbeats or skipped beats?

Are your ankles often badly swollen?

Do you often have difficulty breathing?

Do cold hands or feet trouble you even in hot weather?

Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?

Do you suffer from frequent cramps in your legs?

Do you get out of breath long before anyone else?

Do you sometimes get out of breath when sitting still or sleeping?

Has a doctor ever told you your cholesterol level was high?

Has a doctor ever told you that you have an abdominal aortic aneurysm?

Has a doctor ever told you that you have critical aortic stenosis?

Comments:

Do you now have or have you recently experienced:

Chronic, recurrent or morning cough?

Episode of coughing up blood?

Increased anxiety or depression?

Migraine or recurrent headaches?

Medical History(continued): Check all that apply

Swollen or painful knees or ankles?

Swollen, stiff or painful joints?

Pain in your legs after walking short distances?

Injuries to back, arms, legs or joint

Foot problems?

Back problems?

Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea?

Recent change in a wart or a mole?

Exposure to loud noises for long periods?

An infection such as pneumonia accompanied by a fever?

Significant unexplained weight loss?

A deep vein thrombosis (blood clot)?

A fever, which can cause dehydration and rapid heartbeat?

A hernia that is causing symptoms?

Foot or ankle sores that won’t heal?

Persistent pain or problems walking after you have fallen?

Significant vision or hearing problems?

Glaucoma or increased pressure in the eyes?

Eye conditions such as bleeding in the retina or detached retina?

Cataract or lens transplant?

Laser treatment or other eye surgery?

Heart attack if so, how many years ago?

Rheumatic Fever

Heart murmur

Diseases of the arteries

Varicose veins

Arthritis of legs or arms

Diabetes or abnormal blood-sugar tests

Dizziness or fainting spells

Phlebitis (inflammation of a vein)

Epilepsy or seizures

Stroke

Diphtheria

Scarlet Fever

Infectious mononucleosis

Nervous or emotional problems

Anemia

Thyroid problems

Pneumonia

Bronchitis

Asthma

Other lung disease

Abnormal chest X-ray if so, how many years ago?

Broken bones

Jaundice or gallbladder problems

Comments:

Hormone Health: Check the box(s) that pertain to you

Waking up in the morning not feeling refreshed and well rested

Feeling like I need to take a nap in the middle of the day

Needing to rely on caffeine or other stimulants

Not getting an adequate full night’s sleep

Recent changes in your sex drive

Difficulty with sexual arousal

Changes in your enjoyment of life or loss of motivation

Weight changes or difficulty maintaining your weight

Recent difficulty managing your stress

Past diagnoses of any hormone related condition

Please list any prescription medications you are currently taking:

List any self-prescribed medications, dietary supplements, or vitamins you are now taking:

Please list any drug allergies:

For Women only:

Age at onset of menstruation:

Date of last menstruation

Period every # days:

Number of pregnancies:

Number of live births:

Date of last pap:

Date of last mammogram:

Women only(continued)Please check Yes or No:

Are you pregnant or breastfeeding?

Yes

Heavy Periods, irregularity, spotting, pain or discharge?

Yes

Have you had a D & C, hysterectomy, or cesarean?

Yes

Any urinary tract, bladder or kidney infections within the last year?

Yes

Any blood in your urine?

Yes

Any problems with control of urination?

Yes

Any hot flashes or sweating at night?

Yes

Do you experience vaginal dryness/painful intercourse?

Yes

Experienced any recent breast tenderness, lumps or nipple discharge?

Yes

Please explain any “yes” answers referenced above:

Please sign below, indicating that you have answered the questions accurately and to the best of your ability.

Date Signed

BHRT and Pregnancy Disclaimer, Warning, and Patient Agreement (Premenopausal Women)

I understand that testosterone replacement therapy is not to be used by female patients who are pregnant or trying to become pregnant. I have been counseled on the potential risks of using testosterone replacement therapy during pregnancy, particularly the fact that testosterone usage in pregnant women has sometimes been shown to partially masculinize the external genitalia of a developing female fetus (potentially resulting in an enlarged clitoris, ambiguous genitalia, etc). Furthermore, I understand that I should not be taking estrogen or progesterone supplementation while pregnant or trying to become pregnant.

Pregnancy is a very intricate and delicate hormonal process and any exogenous hormones taken during pregnancy may have a detrimental effect on that process. With these risks in mind, I agree to use a consistent and reliable form of contraception while on hormone replacement therapy to reduce the chances of pregnancy. Additionally, I agree to immediately notify Optimal Medicine, if at any time that I am taking BHRT: I decide to attempt to become pregnant, decide to discontinue contraception, or discover that I am pregnant so that they can quickly and safely discontinue my hormone replacement therapy.

I acknowledge understanding of the above-mentioned disclaimer/agreement and agree to release Optimal Medicine staff and healthcare practitioners from any claims of liability for any potential adverse outcomes that may result from my failure to comply with this agreement.

Initial below:

I truthfully state that I am not currently pregnant.

I truthfully state that I am not currently breastfeeding nor will breastfeed during administration of any prescribed medications or supplements. I understand that it is suggested that I not breastfeed after the last dose of medication/nutritional supplement is taken until I have consulted with my provider at Optimal Medicine.

If I decide to forgo the advice provided by the Optimal Medicine staff and breastfeed while administering any prescribed medications or supplements, I do not hold Optimal Anti- Aging Functional Medicine accountable for any harm caused to either myself or infant.

Date

BHRT Informed Consent to Treat

The Nature of the Treatment

I hereby give my consent to evaluation and treatment by Optimal Medicine’s staff and healthcare practitioners of the following specified condition(s):

Women: menopause or menopausal symptoms (including potential repletion of estrogen/estradiol, progesterone, DHEA, testosterone)

Men: andropause or associated symptoms (including potential repletion of testosterone and DHEA, potential lowering of estrogen/estradiol levels)

Men/Women: other hormone imbalances (*please specify in other) - Thyroid abnormalities, Growth hormone abnormalities including decreased or suboptimal IGF -1, decreased or suboptimal Vitamin D-3 levels.

Men/Women: other (*please specify in other) – Nutritional deficiencies (vitamins, minerals, amino acids, etc)

– may include IV infusion supplementation, Overweight/Obesity (may include medically supervised weight loss with appetite suppressants – phentermine -, injectables (Lipo-C), etc.

Men/Women: other

I agree to the administration of hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and antioxidants and/or drugs designed to alter hormone levels, all as appropriate to my specific diagnosis, particular condition and treatment objectives.

Alternative Treatment Methods and Their General Nature

The reasonable alternatives to this treatment have been explained to me and they include:

Leaving the hormone levels as they
Treating age related diseases as they
Using pharmaceutical agents that are not bioidentical in nature (synthetics)

I understand the foregoing alternatives and am choosing to consent to the treatment plan prepared for me by Optimal Medicine to address the condition(s) indicated above.

The General Nature and Extent of Treatment- Related Risks

Women: I understand that the possible side effects for women on estrogen, progesterone and/or testosterone may include breast swelling and/or discomfort, fluid retention, dizziness, thickening of the lining of the uterus (break-through bleeding), acne, unwanted hair growth, headaches, slight deepening of the voice, slight enlargement of the clitoris, potential increased risk of blood clots, and worsening of (1) ovarian cysts, (2) uterine fibroids, (3) endometriosis, and (4) fibrocystic disease. Many of these effects can be temporary as your body adjusts to restoration. Some of these potential side effects can often be addressed by adjusting hormone levels or prescribing simple remedies. I also understand that if topical hormone replacement treatment (cream, gel, etc) is prescribed for me that I should take extreme care to avoid any collateral exposure via direct skin-to -skin contact with the application site or exposure to contaminated bed linens, clothes, etc. for any children, pets, co-habitants of the home, or anyone else whom may come into contact with the hormonal treatment cream/gel. I have been informed that accidental collateral exposure may significantly impact the hormone levels of those affected.

Men: I understand that the possible side effects for men on testosterone replacement are acne, persistent erections, unwanted hair growth/loss, enlargement of the prostate, enlargement of breast tissue (we will monitor and treat estrogen levels), minor testicular atrophy, salt retention, increase in blood pressure, decreased sperm count, an increase in the number of red blood cells (erythrocytosis) with corresponding increase in hematocrit and/or hemoglobin (your blood will be monitored for this). Many of these effects can be temporary as your body adjusts to restoration. Some of these potential side effects can often be addressed by adjusting hormone levels or prescribing simple remedies. I also understand that if topical hormone replacement treatment (cream, gel, etc) is prescribed for me that I should take extreme care to avoid any collateral exposure via direct skin-to-skin contact with the application site or exposure to contaminated bed linens, clothes, etc. for any children, pets, co -habitants of the home, or anyone else whom may come into contact with the hormonal treatment cream/gel. I have been informed that accidental collateral exposure may significantly impact the hormone levels of those affected.

Safety of Hormone Replacement

Although, in my physician’s opinion, the majority of data points toward safety, there remains controversy regarding the correlation between the use of bioidentical hormone therapy and cancer. Recent data demonstrates that natural progesterone and estriol/estradiol may be protective against breast cancer.

I understand that careful surveillance and close monitoring are requirements of all patients to minimize any possible risk. I understand that Optimal Medicine will monitor my hormone levels and various other laboratory values as they pertain to my treatment goals. However, I also understand that an integral part of health maintenance is obtaining and remaining up to date with age appropriate screening tests aimed at early detection of life-threatening diseases.

Male patients: I,

Optimal Medicine’s staff or healthcare practitioners responsible or liable for performing these screenings or treating/managing any abnormal findings relating to these screenings. I acknowledge that Medicine would like to be supplied with copies of my most current and any future screening results and that, if I do not have them at my initial visit, by signing this consent I express my desire to initiate my treatment at Optimal Medicine and give permission to Optimal Medicine’s staff and healthcare providers to commence treatment without first knowing the results of or reviewing said screenings. In doing so, I release Optimal Medicine’s staff and healthcare providers of any claims of liability for prostate cancer, breast cancer, testicular cancer, and/or colon cancer.Further, I agree to immediately notify Optimal Medicine’s staff and healthcare providers of any abnormal findings on above-noted screenings and supply a copy of any applicable records for their review.

Female patients: I agree to obtain and remain up to date on all age-appropriate screenings including, but not limited to, colonoscopy, PAP smear and pelvic exam, Mammogram and breast exam, DEXA scan, and cardiac screenings as necessary (stress test, etc.). I agree to obtain these screenings through the appropriate physician(s) (PCP, OBGYN, cardiologist, etc) and will not hold Optimal Medicine’s staff or healthcare practitioners responsible or liable for performing these screenings or treating/managing any abnormal findings relating to these screenings. I acknowledge that Optimal Medicine would like to be supplied with copies of my most current and any future screening results and that, if I do not have them at my initial visit, by signing this consent I express my desire to initiate my treatment at Optimal Medicine and give permission to Optimal Medicine’s staff and healthcare providers, to commence treatment without first knowing the results of or reviewing said screenings. In doing so, I release Optimal Medicine’s staff and healthcare providers of any claims of liability for breast cancer, cervical cancer, ovarian cancer, uterine cancer, and/or colon cancer. Further, I agree to immediately notify Optimal Medicine’s staff and healthcare providers of any abnormal findings on above-noted screenings and supply a copy of any applicable records for their review.

Female patients (IF APPLICABLE): I,

(please print), understand that it has been more than one year since my last mammogram.

The health professionals at Optimal Medicine strongly recommend annual mammograms because we consider these vital in the early detection of breast cancer.

I agree and understand that it is not the responsibility of Optimal Medicine’s staff or healthcare providers to perform my recommended Mammogram screening and breast exam.

I also understand that certain types of breast cancer, once present, may be stimulated by estrogen including my own body’s estrogen, and taking estrogen therapy with a present/active breast cancer may worsen the chances of survival.

I also understand there are possible benefits associated with this therapy but that no guarantee has been made to me regarding outcomes of this treatment. I also understand that the benefits derived from antioxidant therapy and vitamin therapy will cease and those derived from hormone therapy and drugs that alter hormone levels will reverse if the therapy is discontinued.

I also understand that if I am female and become pregnant, I should stop the entire treatment protocol immediately and notify my physician (see separate disclaimer and warning). I understand that this hormone therapy is not for the purpose of preventing pregnancy, and that if I become pregnant on this therapy it could present risk to the fetus (unborn child).

Female patients (IF APPLICABLE): I,

(please print), understand that it has been more than one year since my last mammogram.

The health professionals at Optimal Medicine strongly recommend annual mammograms because we consider these vital in the early detection of breast cancer.

I agree and understand that it is not the responsibility of Optimal Medicine’s staff or healthcare providers to perform my recommended Mammogram screening and breast exam.

My Obligations and Representations

Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the hormones prescribed to me. I will comply with the recommended dose and methods of administration. I also agree to participate in the initial and subsequent hormone testing, as required to safely monitor and treat my hormone levels.

I certify that I am under the regular care of another physician (Primary Care Physician, OBGYN, Urologist, etc.) for all other medical conditions. I will consult my physician(s) for any other medical services I may require. I understand that this is a specialized practice. I also understand that I will continue under the care of my other physician(s) for any on-going medical condition as well as for any medical consultation that I may need.

Being aware of all aforementioned facts and notices in this document, and after weighing potential risks vs potential benefits, I elect to commence the aforesaid treatment at Optimal Medicine’s staff or healthcare providers, and assume full liability for any adverse effects that may result from the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the therapy, except as that claim pertains to grossly negligent administration of the therapy.

I fully understand the nature and purpose of portions of the aforementioned treatment may be considered experimental because of the lack of adequate scientific evidence or peer-reviewed publications supporting the underlying premise of bioidentical hormone replacement therapy and that such therapy might even be considered by some medical professionals to be medically unnecessary because it is not aimed at treating a particular disease.

I understand that I may suspend or terminate treatment at any time and hereby agree to immediately notify the physician of any desire to suspend or terminate this treatment so that such suspension or termination may be done safely.

Consent

I hereby authorize my physician to evaluate and treat the conditions I specified on the above pages (this is a

4-page document). I understand my physician may be assisted by other health professionals, as necessary, and agree to their participation in my care as it relates to the evaluation and treatment of the conditions this Consent to Treat covers. I certify that I am 18 years of age or older, am competent to sign this Consent to Treat, and have done so of my own free will.

Date Signed

Patient Authorization for Delivery of Medications

(print name and DOB) hereby authorize the clinic’s staff on duty to act on my behalf to accept medication delivery from the clinic’s dispensing physician and deliver my medications and refills to me as prescribed by my physician.

I understand that delivery of such medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

Any orders delivered damaged or incomplete must be reported to Optimal Medicine; referred to as OAM within 24 hours of delivery and the pictures of damaged package / product must be sent to info@optimal-medicine.com.

OAM is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned and delivered to the customer's address, it is up to the customer to report any missing or stolen packages to OAM within 24 hours of delivery date.

Any packages returned for an INCOMPLETE/ INCORRECT address can be shipped again at the patient's expense.

No Guarantee of Services

We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and physician’s examination.

At the physician’s discretion only, you will be provided medications and/or services during your program at Optimal Medicine.

OAM requires you to have an annual consultation with our provider and annual lab work done. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time.

No Refund Policy

*Optimal Medicine reserves the right to have NO RETURN and NO REFUND policy.

Today’s Date

FINANCIAL POLICY

Payment is due at the time of treatment. We accept several methods of payment including cash, check, major credit/debit cards. If a balance has exceeded $200.00 or existed over 90 days, your privilege to schedule appointments will be suspended until the account is current. In the event of unforeseen circumstances, please communicate with our office to arrange and sign a payment plan. If you have questions on your recommended treatment plan or the available payment options, please do not hesitate to ask. We are here to help you!

Missed Appointment Policy: Your appointment time is reserved for you; please arrive on time to maximize your time with the doctor. Please give 24-hour notice if you are unable to keep your appointment, or a $50 fee may be applied to your account.

General (non-insurance): Fees are to be paid at time of service. Charges will be based on the treatment you receive, which may include a consultation, labs, and other supportive care.

Private Insurance: Optimal Medicine currently does not bill insurance

I have read and understand the office policies and fees of this office. I understand that I am ultimately responsible for payment of my care and any fees incurred.

Date / Time

Photo Identification Requirement:

Please upload a photo copy image of your Driver's License or State ID (front and back).

Name:

DOB

Drivers License or State ID #:

State Issued:

Patient-Physician Contract

We are now in a new era of Health Care Reform - intended to help patients. Sadly, these reforms do not include any “Lawsuit Reforms” that would dramatically reduce costs for patients and also promote a better environment for patients and their physicians. In a recent nationwide poll* 83% of the nation’s electorate wanted Congress to address the medical malpractice system as part of the Health Care Reform plan. We wish Congress had taken action implementing reforms that both doctors and patients could support. And the majority of patients agree. Congress missed the opportunity. Because of that we have taken action with the single goal of enhancing the relationship between patients and the physician.

We take great pride in our reputation for providing the highest levels of quality medical care to our patients. However, we realize there are times when some patients will not be satisfied with the outcomes of their treatments. We also recognize that in these instances, a patient has every right to pursue legal action if he/she feels we have been negligent in some way. We respect every patient’s right to do so.

While some healthcare legal claims are justified, there are also frivolous legal claims filed in our country—claims that are driving up insurance rates and impacting court decisions for the patients who truly deserve compensation. We believe that an agreement early in the treatment process regarding the use of properly credentialed experts will help expedite resolution of concerns.

OUR COMMITMENT TO YOU

We commit to using only properly credentialed expert medical witness(es) in any legal situation, who follow the code of ethics of our national specialty society. These steps ensure that expert medical witnesses we use have passed examinations, demonstrated expertise in their field and adhere to a solid code of ethics.

We demonstrate this commitment to you with our signature on this form. WHAT WE ARE ASKING YOU TO DO

We are asking you or any representative to commit to this process also, by using only properly credentialed physician(s) as expert medical witness(es) if you are dissatisfied with your medical care and decide on legal action.

We hope, and believe, you will never have to consider this again. But if you do, we will honor this commitment to you.

* Poll conducted by Clarus Research Group (www.ClarusRG.com), a nonpartisan survey research firm based in Washington, DC

AGREEMENT AS TO RESOLUTION OF CONCERNS

“I”, “Patient/Guardian” shall be understood to mean (Please print)

“Physician” shall be understood to mean Leah Sullivan FNP-BC and Optimal Medicine. Further, I understand that I am entering into a contractual relationship with a Physician for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agree not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I (the patient) and/or my representative agree to use properly credentialed expert medical witness (es) by the same specialty board as Physician. Furthermore, I agree that these expert witnesses will be members in good standing of and adhere to the guidelines and / or code of conduct defined for expert witnesses by the AANP. Finally, you (the patient) agree that counsel for me (Physician) shall have the right and be free to depose such expert witnesses at least 120 days before any scheduled trial date. In further consideration for this, I, (the Physician), agree to the same stipulations. Patient/Guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/Guardian and Physician agree in the event of a breach to allow specific performance and /or injunctive relief.

Leah Sullivan FNP, BC Provider

Patient/Guardian (please print)

Treatment Start Date

Authorization for Release of Medical Records

*This document MUST be signed by the patient in order to receive copies of their complete medical records including but not limited to test results and treatment plan for themselves.

(please print),

DOB:

authorize the following health care provider(s) to release specified protected health information to Optimal Medicine at the following address:753 SW 11th St. Ste A, Redmond, OR 97756.

The health care provider(s) authorized to release this information are: (please print)

Provider Name

Office phone #:

Office fax #:

B.I authorize the following health information to be disclosed:

My complete medical records and information: including but not limited to, test results, as well as information related to HIV status, drug and alcohol usage, and mental health status (but this authorization does not include the release of psychotherapy notes).

My medical records only for the specific treatment dates from

The following described portions of my medical records and private health information:

C. I authorize this health information to be used and/or disclosed for the purpose of assisting the health care provider, Optimal Medicine, provide treatment to me.

D. I authorize (spouse/caretaker/partner/other)

to receive my protected health care information and/or call on my behalf for the reasons listed, but not limited to, below:

My complete medical records and information: Test results, Appointments and scheduling, Physical exam notes, treatment plan

Requesting medication and/or lab test orders.

This Authorization expires:

On the following date:

Date / Time

When the following event occurs:

F. I understand the following with respect to this Authorization:

a). I have the right to revoke this Authorization at any time by providing the disclosing health care provider(s) with a written request specifically stating my desire to revoke this Authorization. The disclosing health care provider(s) must accept this revocation and may not refuse to continue to provide me with health care treatment. If I revoke this Authorization, it is effective except to the extent that any disclosing health care provider has already used or disclosed my protected health information in reliance on this Authorization.

b.) If someone other than me has initiated the request for the use and/or disclosure of the information described above, I may inspect or copy the information to be used and/or disclosed and then revoke this Authorization.

G. A faxed copy and/or a photocopy of this Authorization shall be as valid as the original signed copy.

*This document MUST be signed by the patient in order to receive copies of their complete medical records including but not limited to test results and treatment plan for themselves.

Date Signed