Patient Intake Form

Patient Full Name:
Date of Birth:
Mobile Number:
Home Number:
Email:
Street Address:
City, State, Zip:
Sex:	—Please choose an option—MaleFemale
Referred By:

Current Goals

What is (are) your purpose(s) for participating in this HRT program? To determine my current level of health and to receive a possible recommendation for an HRT program.Other (please explain):

What are your top 3 goals you want to get out of this program?

Health Habits & Lifestyle

How many days per week do you exercise?
Are you on a diet?
Are you sexually active?	—Please choose an option—YesNo
Are you trying to conceive?	—Please choose an option—YesNo
What do you use for birth control?	—Please choose an option—birth control pillscondomsIUDtubalNuvaRingimplantvasectomydiahragmDepo-ProveraNothing

Current Medical History

Current medical problems (please list):

Male & Female Symptoms - Answer All Questions Choose yes if you experience any of these symptoms or would like to improve in this area below.

Concentration difficulties:	YesNo
Increased sense of stress:	YesNo
Low libido/sex drive:	YesNo
Decreased motivation:	YesNo
Low energy:	YesNo
Decreased muscle strength:	YesNo
Difficulty sleeping:	YesNo
Memory issues:	YesNo
Loss of confidence:	YesNo
Decreased sense of wellbeing/depressed:	YesNo
Mood swings:	YesNo
Decreased skin elasticity/wrinkles:	YesNo
Suffer from joint/tendon pain:	YesNo
Suffer from muscle/body aches and pain:	YesNo
Thinning or loss of hair:	YesNo
Suffer from facial or body acne/skin blemishes:	YesNo

Check all conditions that apply to you:

General	Hot FlashesNight SweatsUnusual FatigueNone-N/A
Metabolic/Endocrine	Cold IntoleranceHeat IntoleranceExcessive ThirstNone-N/A
Musculoskeletal	Joint PainJoint SwellingNone-N/A
Immunologic	Environmental AllergiesFood AllergiesNone-N/A
Neurological	HeadachesSeizuresMemory LossNone-N/A
Reproductive	Vaginal DrynessPain with SexLow LibidoVaginal DischargeIrregular PeriodsHeavy PeriodsMenstrual CrampsNone-N/A
Mental Health	AnxietyDepressionInsomniaSuicidal ThoughtsNone-N/A
Other:
Comments:

Men and Women: Medication History

List any prescription medications and dosages that you are currently taking:
Are you allergic to any medications?	YesNo
List allergies to any medications:
Please list any over-the-counter medications, dietary supplements, or vitamins you are currently taking:
Have you ever used hormones?	YesNo
Are you currently on therapy and what, if so?
Do you drink alcohol?	YesNo
Number of drinks per week:

Women: Please answer the following. Do you have:

Date of last menstrual cycle:
OR Age at menopause:
Irregular periods?	YesNoN/A
Any recent changes in your periods?
Comments:

Amazing Meds does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign up process and physician’s examination.
At the physician’s discretion you will be provided medications and/or services during your program at Amazing Meds.

Amazing Meds reserves the right to have a NO RETURN and NO REFUND policy.

Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, it is important to be sure that you have information about the risks and benefits of hormone therapy before you begin the treatment we discuss. HRT is approved by the FDA for prescribed deficiencies only. Using it for other symptoms or problems is considered “off-label” use, and the liability is on the patient, not the practice or the medical provider. When hormone levels are brought back to “normal” for your age, there is clinical evidence that your overall health will benefit. HRT is the most effective treatment for hormone deficiencies. There may also be other long-term beneficial effects of treatment. Because standard practices continue to change as medical technology advances and more studies are conducted, it is important to discuss HRT with your doctor each year at your annual exam to find out what the newest information is.

Please read the following and sign below: I have discussed the reasons for taking female/male hormones with my provider. I understand why they are prescribing them, as well as the risks associated with taking hormones that include but are not limited to: the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are different associated risks if I take any HRT medication. I have discussed with my medical provider these risks and the reasons for taking these medications. I understand that my provider will do everything they know to do to decrease and minimize the risks of HRT. I understand that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above, as well as others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them to me.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party (Amazing Meds).
I understand that uses and disclosures already made based upon my original permission cannot be taken back.
I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.
I understand that treatment by any party may not be conditioned upon my signing of this authorization and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Telehealth or telemedicine involves the use of the Internet to facilitate electronic communication to enable healthcare providers at different locations to share individual patient medical information for the purpose of treatment and improving patient care. Providers may include medical practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, treatment, follow-up and/or education, and may include any of the following:
● Patient medical records
● Medical images or lab results
● Live two-way audio and/or video
● Output data from medical device and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification, and Amazing Meds will implement measures to safeguard patient data against intentional or unintentional corruption.

By signing this form, I understand the following:
1. I understand that the laws to protect privacy and confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time. (Depending on the patient's location, this may affect future care and treatment since Amazing Meds is located in Colorado Springs, Colorado).
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. Amazing Meds has explained the
5. I understand that I may expect anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I have read and understand the information provided above, have discussed it with my provider or Amazing Meds team as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my care.
I hereby authorize Amazing Meds to use telemedicine in the course of my diagnosis and treatment.

Card Type:	—Please choose an option—MasterCardVISADiscoverAMEX
Name on Card:
Credit Card Number:
Expiration Date:
CVC Security Code:
Billing Address:
City:
State:
Zip Code:

By signing below, I acknowledge that all information listed above is as accurate as possible and I also agree to all terms and conditions listed above.By signing this form, you give Amazing Meds permission to keep the above card information on file to authorize for charges towards treatment (including, but not limited to: lab work, provider visit fees, and for prescribed medication). We will obtain your verbal or written consent prior to authorizing your card for payment when applicable.

Authorized Signature:
Today's Date:

*Amazing Meds reserves the right to have a NO RETURN and NO REFUND policy.
**All orders will be processed once the payment clears. Please allow 10 business days for all orders to be processed.