Men’s Complete Health

Male Care MD, LLC

1250 S. Tamiami Trail, Suite 200

Sarasota, Florida, 3429-2221

Phone (941)2013-8944

Fax(866)248-2148

Male Intake Form

MALE HRT PATIENT INFORMATION FORM

Marital Status *
MEDICAL INSURANCE INFORMATION (Information used for lab work only. Please provide your insurance card)

MALE HRT PERSONAL HEALTH HISTORY

General:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Psychiatric:
Allergies
Exercise:
Tobacco:
Illicit drug use:

Patient Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed the Notice of Privacy Practices of Men’s Complete Health.

Please initial one of the following: *
Please read and initial ALL below: *

Agreements and Authorizations: Consent to Release of Information

You authorize Men’s Complete Health, LLC / Male Care MD, 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 Men’s Complete Health, LLC
/ Male Care MD, 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 Men’s Complete Health, LLC / Male Care MD, 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 Men’s Complete Health, LLC / Male Care MD, 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.

SYMPTOMS OF LOW TESTOSTERONE LEVELS

Decreased concentration
Difficulty learning new things
Memory loss
Moodiness
Depression
Increasing fatigue
Decreasing energy
Poor sleep habits
Erectile dysfunction
I have had testosterone checked previously
I have used testosterone previously

Consent for Testosterone Replacement

A FEW THINGS TO KNOW ABOUT HORMONE REPLACEMENT (MALE HRT)

It 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 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 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: Initial beside each statement that you have read, understand and agree with. *

I, ____________________________, agree that, while a patient of Men’s Complete Health, LLC / Male Care MD, LLC, I will not take any type of anabolic steroids, testosterone gels, hormone “boosters,” pro-hormones or any additional testosterone supplementation not provided by Men’s Complete Health, LLC / Male Care MD, LLC during my treatment plan. At any time, if use of these items is discovered, I understand I may be discharged as a patient of Men’s Complete Health, LLC / Male Care MD, LLC.

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)?
Do you have a lack of energy?
Do you have a decrease in strength and/or endurance?
Have you lost height?
Have you noticed a decreased “enjoyment of life” ?
Are you sad and/or grumpy?
Are your erections less strong?
Have you noticed a recent deterioration in your ability to play sports?
Are you falling asleep after dinner?
Has there been a recent deterioration in your work performance?

If you answered yes to number 1 or 7 or if you answer yes to more than 3 questions, you may have low Testosterone.