Medical History Form

Personal information

First Name
Email Address
Date of Birth
Gender
Last Name
Drivers License
Weight
Height

ADDRESS & NUMBERS

Address
Address 2
City
State
Zip
Country
Home
Best Time To Call
Work
Best Time To Call
Cell
Best Time To Call

OTHER

Occupation
Have you already contacted Elite Medical Group? Please provide the name of your Medical Advisor

SOCIAL HISTORY

Do You Smoke?
 Yes No
Do You Drink Alcohol?
 Yes No
Do You Exercise?
 Yes No
Do You Take Supplements?
 Yes No
Please Explain Social History. Smoking and/or Drinking Frequency. Exercise Type and Frequency. Type of Supplements and Dosages.

DIAGNOSED HISTORY OF MEDICAL CONDITIONS/DISEASE

Do you currently have or ever had any of the following?
If yes, please check below and explain in the provided field:

Blood Disorders
 Yes No
Immune Disorders
 Yes No
Cancer
 Yes No
Chemical Dependency
 Yes No
Carpal Tunnel Syndrome
 Yes No
Lung Disorder
 Yes No
Allergies to Medications
 Yes No
Upper Respiratory
 Yes No
Edema / Excess Fluid Retention
 Yes No
Poor Wound Healing
 Yes No
Any Known Deficiency Including Minerals and Electrolytes
 Yes No
Use of medications (If Yes, Please List Medications Below)
 Yes No
Orthopedic or Muscle Disorder Including Fracture or Joint Disorders
 Yes No
Emotional Disorders / Depression
 Yes No
Renal Disease
 Yes No
Genital - Urinary Disorder
 Yes No
Hyperlipidemia
 Yes No
Hypertension
 Yes No
Neurological Disorders
 Yes No
Arthritis
 Yes No
Bursitis
 Yes No
Rheumatism
 Yes No
Sports Injury(s)
 Yes No
Thyroid, Diabetes or Other Endocrine Disorder Including Insulin Resistance
 Yes No
Heart Disease Including Atherosclerosis, Angina, Heart Failure, Heart Attack
 Yes No
Other Illnesses
 Yes No
Explain The History Of Any Above Checked Conditions or Diseases
List All The Medications You Are Taking. Please Be Specific (Name, Dosage, etc.) or Specify "NONE"

STEROIDS / HORMONES

Prior History of HRT, Steroid or Other Hormone Use?
 Yes No
Prior Medical Records / Labs?
 Yes No
Explain Prior History of HRT, Steroid or Other Hormone Use. Please Be Specific (Name, Dosage, etc.)

PRIMARY PHYSICIAN INFORMATION

Physicians Name
Phone
Date of Last Physical Exam With Above Physician

FAMILY HISTORY

Does an immediate family member currently have or ever had any of the following?
If yes, please check below and explain in the provided field:

Cardiovascular Disease
 Yes No
Diabetes, Thyroid or Other Endocrine Disorder  
 Yes No
Hypertension
 Yes No
Lipid Disorder
 Yes No
Prostate Cancer
 Yes No
Other Forms of Cancer
 Yes No
Other Illnesses
 Yes No
Explain Family Health History

SYMPTOMS

Prospective Patients: Please check the symptoms you hope to improve through hormone replacement therapy (HRT).

Existing Patients: Please check the symptoms you have improved and hope to continue to improve through HRT.

Increased Lack of Drive
 Yes No
Increasing Fat Deposits Around The Abdomen and/or Thighs
 Yes No
Increasing Mood Swings
 Yes No
Increasing Sagging Muscles or Breasts
 Yes No
Increasing Wrinkles
 Yes No
Increasingly Stressed
 Yes No
Decreased Desire and Ability To Exercise
 Yes No
Decreased Energy or Endurance
 Yes No
Decreased Sense of Well-Being
 Yes No
Decreasing Memory
 Yes No
Decreasing Muscle Strength
 Yes No
Decreasing Size of Testicles
 Yes No
Cold or Heat Intolerance
 Yes No
Currently Pregnant
 Yes No
Depression
 Yes No
Progressive Osteoporosis, Decreasing Bone Mass or Stooped Posture
 Yes No
Difficulty Sleeping
 Yes No
Headaches / Migraines
 Yes No
Hot Flashes
 Yes No
Loss of Concentration, Sociability, Activity
 Yes No
Loss of Interest In Sex
 Yes No
Muscle Loss
 Yes No
Sagging, Loose or Thin Skin
 Yes No
Sore Muscles, Joint Pain(s) or Swelling
 Yes No
Thinning or Loss of Hair
 Yes No
Urogenital Atrophy
 Yes No
Weight Loss - Unexplained
 Yes No
Other
 Yes No
PLEASE USE THIS SPACE TO EXPLAIN ANY ADDITIONAL INFORMATION

Signature

Patient Authorization and Agreement

The undersigned Patient ("Patient") authorizes and instructs Elite HRT ("Elite HRT") to provide the Patient with medical management, administrative and referral services. Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement ("Agreement"). Patient submits with this Agreement an accurately completed Medical History Form ("MHF"). Patient agrees to respond truthfully, accurately and completely on the MHF and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to the Physicians referred by Elite HRT ("Physicians") could result in inappropriate treatment. Patient authorizes Elite HRT to receive copies of reports from medical laboratories, diagnostic testing services, Physicians and dispensing pharmacies relating to his/her treatment. In addition, Patient authorizes and instructs Elite HRT, Physicians and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the information contained on the MHF, laboratory diagnostic tests, and other information submitted to Elite HRT under this Agreement. Patient agrees to present photo identification upon receiving any blood testing pursuant to a Elite HRT or Physician test requisition. Patient acknowledges that medications, laboratory and diagnostic testing and medical services supplied or obtained by Elite HRT, are not covered or reimbursed by Medicare, Medicaid or any other insurance.

Patient specifically swears and acknowledges that he or she is not a professional or amateur athlete/bodybuilder. Patient specifically swears and acknowledges that he or she is not seeking treatment or prescription medication by Elite HRT and/or Physician for the purpose of athletic performance or cosmetic enhancement. It is outside the scope of Elite HRT and the Physician to provide these services or prescriptions under those circumstances. Elite HRT and the Physician only provide treatment and prescription medication to patients who have a deficiency and medical need as established by laboratory blood tests, physical examination, this MHF and in the sole determination of the Physician.

Patient acknowledges that Elite HRT's employees and advisors are not licensed physicians and that Physicians obtained on my behalf by Elite HRT are independent contractors, compensated by Patient with funds provided to Elite HRT. I further understand and agree that Elite HRT and Physicians are rendering the medical care, services and treatment, and that Elite HRT is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by any pharmacy in my country of residence.

Patient agrees to comply with the method of instructions, treatment and dosage schedules prescribed by Physician: To immediately cease any medical treatment prescribed by Physician in the event of any adverse reaction or side effect arising from prescribed treatment and to immediately provide Elite HRT and Physician with written notice of any such adverse reaction or side effect. I further acknowledge and agree that Elite HRT is not liable for any negligent act or omission of the Physician.

Patient acknowledges that diagnosis and treatment may involve risk of injury, and that Elite HRT and Physician have made no guarantees or warranties with respect to the above described diagnostic testing, analysis of test results, examination of medical history or hormone treatment. Patient acknowledges that the hormone blood level objective sought as a result of Patient's hormone replacement therapy, as prescribed by Physician, may be the highest level of standard reference range for Patient's age and sex, or, in some cases, above such range, to the level of a younger person, and that such range is experimental and may not render any benefits, but may result in unknown, adverse results.

Patient is aware of the nature, risk and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone replacement treatment. Patient acknowledges that recombinant human growth hormone replacement therapy involves the use of a medical drug approved for one purpose and being utilized for a new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone replacement therapy for the purpose of authorizing Physician to administer such treatment to relieve body ailments and deficiencies. Patient further acknowledges that the methods of medical treatment offered by Elite HRT and Physician are not accompanied by claims, guarantees, promises or warranties. In compliance with federal and state laws, there will be no refund given for any medication.

Patient is freely seeking medical consultation via the internet and acknowledges and consents to Physician reviewing Patient's medical history without the opportunity to conduct an in-person physical examination. Patient has contacted Elite HRT for a specific prescription medication to treat an already identified medical condition. Patient acknowledges that Physician may not be licensed to practice medicine in Patient's state or country of residence. Further, Patient agrees that Physician's consultations, diagnosis, and treatments will be deemed to have occurred in Florida.

Patient represents that he or she is under the care of a primary care physician and the Physician, he or she will not rely or substitute the advice of Physician should it conflict with the advice given by Patient's primary care physician. Before qualifying for any treatment or any medication prescribed by Physician, Patient agrees to have a comprehensive physical examination and to submit same to become a part of patient's records to be maintained by Elite HRT. Patient agrees to notify his or her primary care physician and advise such physician that Patient is undergoing hormone replacement therapy.

This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Palm Beach County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.

This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void and of no effect. If any provision of the Agreement or the application thereof to any person or circumstances is held invalid or unenforceable in any jurisdiction, the remainder hereof, and the application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable.

Patient agrees to indemnify, defend, protect and hold harmless Elite HRT and Physician and their respective officers, directors, employees, stockholders, assigns, successors and affiliates ("Indemnified Parties") from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demand, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paid by the Indemnified Parties in connection with, resulting from or arising out of, directly or indirectly, Elite HRT and/or Physician's rendering medical care, services, advice and/or treatment.

Patient's failure to disclose all relevant information regarding Patient's medical and physical condition, may result in acts or omissions by Elite HRT or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Elite HRT or Physician. Patient is aware of potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties herein.

 I understand that the medications I have purchased are prescribed for me based on diagnosis derived from my submitted medical history form, blood and lab report, and physical examination. They are to be based exclusively for treatment of this diagnosis.
 I will immediately report any adverse side effects related to the use of my medication to Elite HRT and discontinue use until advised to resume usage by Elite HRT.
 I will safeguard my medications from loss or theft.
 I understand that Elite HRT does not cooperate with any insurance companies.
 I will not sell, share or trade my medications for money, goods or services.
 I agree that I will use my medications at the prescribed rate and dosage, and I will keep the medication in its respective labeled container.
 I will not attempt to obtain scheduled hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is illegal to do so.
 I attest I am not seeking medical treatment for body enhancement, body building, performance enhancement or cosmetic enhancement of any kind. I am seeking this treatment for legitimate medical purposes.
 I have read the text above, and I agree to the terms and conditions disclosed herein.
Digital Signature: Please Print Name
Menu Title