ࡱ>  {` 4bjbjFF .,,,MddККК8|#t "} 3$h3}j}}jj<<<j<j<<4xh @`-КR L0T$^xx8 6A<շDQ ` jjjj###;L_;###L_` Medical Questionnaire IMPORTANT INSTRUCTIONS: Save this form to your computer before filling it out. (File, Save) Hit TAB to move to the next field. Return the completed form to us within 3 days so we may prepare a lab order. Name:  FORMTEXT       Date:  DATE \@ "M/d/yyyy" 1/27/2009 Birth Date:  FORMTEXT       Billing Address:  FORMTEXT       City:  FORMTEXT       ST:  FORMTEXT       ZIP:  FORMTEXT       Shipping Address:  FORMTEXT       City:  FORMTEXT       ST:  FORMTEXT       ZIP:  FORMTEXT       Phone (Home):  FORMTEXT       (Work):  FORMTEXT       (Fax):  FORMTEXT       (Cell):  FORMTEXT       E-mail:  FORMTEXT       Occupation:  FORMTEXT       Social Sec #:  FORMTEXT       Employer:  FORMTEXT       Employer Address:  FORMTEXT       Insurance name and plan:  FORMTEXT       (Lab tests only) Patient relationship to insured (click to select one):  FORMDROPDOWN  Policy ID #:  FORMTEXT       Group/plan #:  FORMTEXT       Employer/group name:  FORMTEXT       Name of Insured party (if not self):  FORMTEXT       Insurance Co Address:  FORMTEXT       In case of emergency contact (Name):  FORMTEXT       Phone:  FORMTEXT       Relationship:  FORMTEXT       Primary Care Physician (Name and phone):  FORMTEXT       Other Physicians (Name, specialty and phone):  FORMTEXT        How did you hear about us?  FORMTEXT       Reason for appointment:  FORMTEXT       List your current medical problems (e.g., diabetes, high blood pressure, chronic fatigue, arthritis) in chronological order, latest to oldest. 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       6.  FORMTEXT       Past Medical History: List all major illnesses and the dates of any associated hospitalizations. For example, pneumonia, hospitalized 2/84. 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       6.  FORMTEXT       7.  FORMTEXT       8.  FORMTEXT       List all surgeries with dates. 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       6.  FORMTEXT       7.  FORMTEXT       8.  FORMTEXT       Please list all prescription medications (incl. doses and frequencies) you currently take (e.g.; Celebrex, 200mg, 1/day):  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Please list all non-prescription medications, vitamins, and supplements you currently take. (incl. doses and frequencies):  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       List any allergies to medications or supplements:  FORMTEXT        FORMTEXT        FORMTEXT       Are any of the following diseases in your immediate family? If yes, please note the age at which the family member contracted the disease. (i.e. Father: at 42) Cardiovascular disease?  FORMTEXT       Diabetes?  FORMTEXT       Colon cancer?  FORMTEXT       Breast cancer?  FORMTEXT       Prostate cancer?  FORMTEXT       Skin cancer?  FORMTEXT       Please list any other diseases that run in your family:  FORMTEXT       What has been your occupation over the past 10 years?  FORMTEXT       Marital status (click to select one):  FORMDROPDOWN  # of Children:  FORMTEXT       Have you ever smoked cigarettes, cigars, or pipes?  FORMCHECKBOX  Yes  FORMCHECKBOX  No How many years?  FORMTEXT       Have you quit?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If so, when?  FORMTEXT       Have you ever used any recreational drugs?  FORMCHECKBOX  Yes  FORMCHECKBOX  No How many years?  FORMTEXT       How much alcohol do you drink? (One drink equals 4 oz. wine, 12 oz. beer, 1 oz. liquor)  FORMCHECKBOX  Less than two drinks a week?  FORMCHECKBOX  2 to 5 drinks a week?  FORMCHECKBOX  6 to14 drinks a week?  FORMCHECKBOX  14 or more drinks a week? The following long and somewhat tedious list is designed to reveal symptoms of aging and early manifestations of disease that you may not have recognized yet. Please check off the boxes that apply or have applied to you, or answer the questions appropriately. General  FORMCHECKBOX  More tired than you would like to be on a daily basis  FORMCHECKBOX  Been depressed recently  FORMCHECKBOX  Lost interest in life recently  FORMCHECKBOX  Anxious on a regular basis  FORMCHECKBOX  Sleep 7 or more hours a night  FORMCHECKBOX  Sleep less than 7 hours a night  FORMCHECKBOX  Loss of ambition  FORMCHECKBOX  Loss of determination  FORMCHECKBOX  Loss of Optimism Cardiopulmonary  FORMCHECKBOX  Chest pain at rest  FORMCHECKBOX  Chest pain with exertion  FORMCHECKBOX  Heart has beat irregularly  FORMCHECKBOX  Short breath with minimal exertion  FORMCHECKBOX  Shortness of breath when you lie flat on your back  FORMCHECKBOX  Ankles swell significantly if you stand or walk for a long time  FORMCHECKBOX  Calves burn if you walk more than a short distance  FORMCHECKBOX  Appears as if a shade were being pulled over either eye for a short time  FORMCHECKBOX  Wheezing Gastrointestinal  FORMCHECKBOX  Frequent heartburn  FORMCHECKBOX  Take antacids frequently  FORMCHECKBOX  Burning in your stomach if you havent eaten for a while  FORMCHECKBOX  Vomited up blood or coffee ground appearing material  FORMCHECKBOX  Sense of being full before eating much of a meal  FORMCHECKBOX  Milk products cause bloating of your stomach, belching, or the passing of gas  FORMCHECKBOX  Take lactose intolerance aids regularly  FORMCHECKBOX  Frequently constipated  FORMCHECKBOX  Loose stools regularly  FORMCHECKBOX  Blood in your stools  FORMCHECKBOX  Hemorrhoids  FORMCHECKBOX  Abdominal cramping regularly with eating  FORMCHECKBOX  Common for you to feel weak, or break into a sweat a few hours after eating  FORMCHECKBOX  Trouble swallowing Neurological  FORMCHECKBOX  Tingling of your hands or feet bother you  FORMCHECKBOX  Intermittent weakness of any of your extremities  FORMCHECKBOX  Frequent headaches  FORMCHECKBOX  Get dizzy if you turn your head quickly  FORMCHECKBOX  Sometimes have difficulty talking distinctly  FORMCHECKBOX  Tremor or shaking of your hands  FORMCHECKBOX  Ability to remember things worsened lately Musculoskeletal  FORMCHECKBOX  Frequent aching of your joints  FORMCHECKBOX  Frequent swelling of your joints  FORMCHECKBOX  Frequent back pain  FORMCHECKBOX  Frequent neck pain  FORMCHECKBOX  Decrease in your muscle tone/size in the past year  FORMCHECKBOX  Aching in your feet or heels when you take you first steps in the morning Endocrine  FORMCHECKBOX  Undue sensitivity to heat or cold  FORMCHECKBOX  Weight loss of 10 lbs. or more in the past 6 months  FORMCHECKBOX  Weight gain of 10 lbs. or more in the past 6 months  FORMCHECKBOX  Weight stayed constant in the past 5 years  FORMCHECKBOX  Increase in fat around your waist in the past 5 years Skin  FORMCHECKBOX  Have dry skin regularly  FORMCHECKBOX  Have dry skin in the winter only  FORMCHECKBOX  Have pimples or acne frequently  FORMCHECKBOX  Skin has been wrinkling more in the past year  FORMCHECKBOX  Bruise easily  FORMCHECKBOX  Get rashes regularly  FORMCHECKBOX  Skin itches regularly  FORMCHECKBOX  Hair dry  FORMCHECKBOX  Hair oily  FORMCHECKBOX  Losing your hair more rapidly lately Men only Do you have a decrease in libido (sex drive)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have a lack of energy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you have a decrease in strength and /or endurance?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you lost height?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you noticed a decreased enjoyment of life?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you sad and /or grumpy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are your erections less strong?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you noted a recent deterioration in your ability to play sports?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you falling asleep after dinner?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Has there been a recent deterioration in your work performance?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?  FORMTEXT       Over the past month, how often have you had to urinate again less than two hours after you finished urinating?  FORMTEXT       Over the past month, how often have you found you stopped and started again several times when you urinated?  FORMTEXT       Over the past month, how often have you found it difficult to postpone urination?  FORMTEXT       Over the past month, how often have you had a weak urinary stream?  FORMTEXT       Over the past month, how often have you had to push or strain to begin urination?  FORMTEXT       Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?  FORMTEXT       Women only When was your last period? Date:  FORMTEXT       When was the period before the last one? Date:  FORMTEXT       At what age did you start your period?  FORMTEXT       How many days is it between periods?  FORMTEXT       How many days of flow do you have during your period?  FORMTEXT       How many of these are heavy flow?  FORMTEXT       Are your cycles regular?  FORMTEXT       Do you suffer from PMS?  FORMTEXT       Do you get breast tenderness at any time during your cycle? When?  FORMTEXT       Do you feel bloated during your cycle? When?  FORMTEXT       Do you get headaches at a particular time during your cycle?  FORMTEXT       Do you get more irritable or emotional before your menstruation?  FORMTEXT       How many periods have you missed in the last year?  FORMTEXT       Do you have hot flushes?  FORMTEXT       Do you have vaginal dryness?  FORMTEXT       Is sexual intercourse painful frequently?  FORMTEXT       Do you have frequent yeast infections?  FORMTEXT       Do you have frequent urinary tract (bladder) infections?  FORMTEXT       On a scale of 1 to 10 (10 highest), how would you rate your sex drive?  FORMTEXT       Has your sex drive changed significantly since you were younger?  FORMTEXT       Has the quality, intensity, or frequency of your orgasms changed?  FORMTEXT       How many times have you been pregnant?  FORMTEXT       How many pregnancies resulted in a birth?  FORMTEXT       How did the other pregnancies end?  FORMTEXT       Do you wear a bra 24 hours per day?  FORMTEXT       Recent Diagnostic Test Results Most recent cholesterol: HDL  FORMTEXT       LDL  FORMTEXT       Triglycerides  FORMTEXT       Most recent PSA (men):  FORMTEXT       Date:  FORMTEXT       Most recent mammogram (women):  FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal Date:  FORMTEXT       Most recent PAP smear:  FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal Date:  FORMTEXT       Have you ever had a Sigmoidoscopy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes:  FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal Date:  FORMTEXT       Have you ever had a Colonoscopy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes:  FORMCHECKBOX  Normal  FORMCHECKBOX  Abnormal Date:  FORMTEXT       Have you ever had a stress test?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, when, and what was the result?  FORMTEXT       Have you ever had a Bone Mineral Density test?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, when?  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FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, when, and what was the result (if you have copy please send it):  FORMTEXT       Exercise Assessment Do you walk each day?  FORMCHECKBOX  Less than 20 min.  FORMCHECKBOX  20 to 40 min.  FORMCHECKBOX  more than 40 min. Do you lift weights regularly? If yes, what is your routine?  FORMTEXT       Do you do cardio training? If yes, how much and how often?  FORMTEXT       Do you participate in any other regular athletic activity? If yes, please describe it.  FORMTEXT       24 hr. diet recall: list all you ate in the last 3 meals, including intervening snacks/beverages. Breakfast:  FORMTEXT       Snack:  FORMTEXT       Lunch:  FORMTEXT       Snack:  FORMTEXT       Dinner:  FORMTEXT       Snack:  FORMTEXT       POLICIES AND PROCEDURES (for your records) Shipping FedEx imposes a $1.50 surcharge on shipments requiring a signature and a $2.00 surcharge on shipments to residences. If you do not require a signature or if you wish to change your address, please let us know. Patients are responsible to accept deliveries or make arrangements to have deliveries left without a signature. PhysioAge is not responsible for loss due to delays beyond our control (i.e.; adverse weather conditions, unsuccessful delivery attempts, etc.) FedEx is not responsible for loss due to delays beyond their control in the delivery of perishable refrigerated medications. Holiday Schedule In general, any shipments scheduled to ship on a holiday will go out on the next business day and will arrive one day later than usual. During Thanksgiving week, all shipments will be scheduled to arrive by Wednesday. The pharmacy will not operate on the following days: 11/22/07 Thanksgiving Day 2/19/07 President s Day 12/25/07 Christmas Day 5/28/07 Memorial Day 1/1/08 New Year s Day 7/4/07 Independence Day 9/3/07 Labor Day In addition, PhysioAge Medical Group will not operate on the following days: 11/23/07 Thanksgiving Friday 10/8/07 Columbus Day 1/15/07 Martin Luther King Day Appointment Policy Appointments must be confirmed at least 2 business days in advance in order to guarantee the time slot. Late cancellations (less than 2 business days notice) will incur a penalty equal to 50% of the office visit fee. Lab Testing Patients receiving medications are required to provide periodic lab test results. Failure to comply with this requirement may result in a suspension of treatment. Except for appointments involving an in-house blood draw, patients are required to provide specimens for testing at least 21 days before their scheduled appointment. Prescriptions Unless otherwise arranged, all prescriptions will automatically refill. Prescription requests submitted before 5PM EST will be shipped on the next business day. No same-day orders will be permitted. Requests can be made by phone (877-PHYSIO-AGE), e-mail ( HYPERLINK "mailto:Rx@PhysioAge.com" Rx@PhysioAge.com) or fax (212-888-7828). If your credit card is declined, your prescriptions will not be filled. The pharmacy will attempt to contact you by phone. If you are not available or if you do not return the call promptly, your order may be delayed. You may eliminate this possibility by providing a deposit equal to the value of one month of medications. Prescription items are not returnable. Please check your order when it arrives and report any discrepancies within 48 hours. Program Maintenance Fee: HRT $75  HCG $100  HGH $125 This fee covers the cost of all follow-up consultations, e-mails, telephone calls, physical exams, analysis and review of laboratory tests, management of your lab follow-up requirements and treatment program, PhysioAge Diagnostic Testing (arterial compliance, body composition, lung health, and skin elasticity), and all the overhead costs of running a full-time age management practice. This fee applies to every 28-day period as long as your physician is responsible for monitoring blood levels, managing your treatment program and treating symptoms. It does not correlate to office visits or shipments, but it is billed with your regular shipments for simplicity. This fee will continue to be billed even if you hold medication shipments unless you notify us of your intent to discontinue the Program temporarily or permanently.  NOTICE OF PRIVACY PRACTICES In compliance with the Health Insurance Portability and Accountability Act of 1996, Privacy Rule We (PhysioAge Medical Group) must make all reasonable efforts to safeguard your protected health information; We must use and disclose your protected health information for the purposes of treatment, payment, and other healthcare operations only; We must obtain your specific authorization to use or disclose your protected health information for purposes other than treatment, payment, or other healthcare operations; We must make information available to healthcare agencies on demand; We must make information available to law enforcement agencies on demand. You have the right: To receive our Notice of Privacy Practices. To revoke an authorization which allows us to use or disclose your protected health information for purposes other than treatment, payment, or other healthcare operations, at any time. To inspect your protected health information. To receive a copy of your protected health information. To request an amendment of your protected health information. To complain about any breaches of privacy.  I have received and read the Notice of Privacy Practices issued by PhysioAge Medical Group. I understand my rights outlined in the Notice in relation to the use or disclosure of my protected health information. __________________________________ _______________ (Patient Signature) (you may sign at the time of your visit) (Date) __ FORMTEXT      _____________________________ (Printed Name) PLEASE RETURN THIS FORM TO US AT LEAST WITHIN THREE DAYS SO WE MAY PREPARE A LAB ORDER. EMAIL:  HYPERLINK "mailto:CONTACT@PHYSIOAGE.COM" CONTACT@PHYSIOAGE.COM NOTE: A valid credit card is required to hold your appointment. Credit Card Authorization I,  FORMTEXT      , authorize PhysioAge Medical Group to charge my (Patient Name)  FORMCHECKBOX  MasterCard  FORMCHECKBOX  VISA  FORMCHECKBOX  AMEX  FORMCHECKBOX  Discover for costs and fees related to my treatment program, including office visits, professional fees and medications. I understand that if I am not able to keep any appointment I must notify PhysioAge Medical Group by phone at least three (3) business days in advance or my card will be charged a non-refundable penalty equal to 50% of the cost of the consultation fee. X Card holder signature Date  FORMTEXT       Name on Card (exactly as it appears)  FORMTEXT        FORMTEXT        FORMTEXT       Credit card number Exp. Date Security Code  FORMTEXT       Billing Address Please sign and fax this page to us at 212-888-7828 within 3 business days in order to keep your appointment.       30 Central Park South, New York, NY 10019 (212) 888-7074 fax (212) 888-7828 Ronald V. Livesey, MD Joseph M. 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