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Home|Female New Patient Information Form
Female New Patient Information FormPeter Kahuria2023-12-12T22:39:06-05:00

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Paradigm Hormones Restorative Clinic - Female New Patient Info

Name:(Required)
MM slash DD slash YYYY
Address:(Required)
Marital Status:(Required)
Children:(Required)
You desire more children?(Required)

Emergency Contact Info

Name:(Required)

Medication List

Drug Allergies:(Required)
Are you currently/have you ever used any form of hormone replacement therapy?(Required)

Main Concerns/Reason for Visit;

Main Concerns/Reason for Visit:(Required)

Please circle any of the following symptoms you have been experiencing if any:

Metabolic:

Weight Gain:(Required)
Night Sweats(Required)
Hot Flushes/Hot Flushes(Required)
Fatigue(Required)
Pain With Intercourse(Required)
Vaginal Dryness(Required)
Sleeping Problems(Required)
Urine Leaks(Required)
Memory Loss(Required)
Mood Swings(Required)
Migraines(Required)
Depression(Required)
Anxiety(Required)
Decreased Sexual Desire(Required)
Trouble Focussing(Required)
Foggy Thinking(Required)
Muscle/Joint Pain(Required)

GYN History

Do you have regular periods?(Required)
Has the flow of your period changed?(Required)
Flow(Required)
If you no longer have a period, please choose a reason(Required)

Are you currently pregnant, trying to get pregnant or breastfeeding?(Required)
Current birth control method(Required)

Abnormal or Post Menopausal bleeding(Required)
Abnormal Pap history(Required)
Abnormal vaginal or cervical history(Required)
Are you sexually active?(Required)
Do you ave sexual problems or pain with sex?(Required)
Do you have any STDs/STIs?(Required)
Do you perform self breast exam?(Required)
Do you have any breast lumps or discharge?(Required)
Do you have a uterus?(Required)

Social History

Smoker?(Required)
Do you chew/dip tobacco?(Required)
Do you use recreational drugs?(Required)
Do you drink alcohol?(Required)
Do you exercise?(Required)
Do you consume caffeine?(Required)

Family History

Breast Cancer:(Required)
Ovarian Cancer:(Required)
Colon Cancer:(Required)
Skin Cancer:(Required)
Kidney Disease:(Required)
Diabetes:(Required)
Lung Cancer:(Required)

Preferred Pharmacy:

Primary Care Physician:

Physician Name:(Required)

NOTICE OF PRIVACY PRACTICES:

Paradigm Hormones has privacy practices in place. The notice describes how medical information about you may be used and disclosed, and how you can get access to this information. By signing this, you acknowledge receipt of Paradigm Hormones Notice of Privacy Practices.
MM slash DD slash YYYY

Please circle any of the following symptoms you have been experienced or currently having:

Medical History:

Select any of them!
Select any of them!
Select any of them!

Surgical History:

Select any of them!
Select any of them!
Select any of them!

CONSTITUTIONAL:

Fever?(Required)
Night Sweats?(Required)
Weight Gain?(Required)
Weight Loss?(Required)
Exercise Intolerance?(Required)

GENITOURINARY:

Urinary Loss of Control?(Required)
Difficulty Urinating?(Required)
Increased Urinary Frequency?(Required)
Hematuria?(Required)
Incomplete Emptying?(Required)

EYES:

Dry-Eyes?(Required)
Irritation?(Required)
Vision Change?(Required)

MUSCULOSKELETAL:

Muscle Aches?(Required)
Muscle Weakness?(Required)
Joint Pain?(Required)
Back Pain?(Required)
Swelling in Extremities?(Required)

EAR/NOSE/_THROAT:

Difficulty Hearing?(Required)
Ear Pain?(Required)
Frequent Nose Bleeds?(Required)
Nose Problems?(Required)
Sinus Problems?(Required)
Sore Throat?(Required)
Bleeding Gums?(Required)
Snoring?(Required)
Dry Mouth?(Required)
Oral Abnormalities?(Required)
Mouth Ulcer?(Required)
Teeth Abnormalities?(Required)

INTEGUMENTARY:

Abnormal Mole?(Required)
Jaundice?(Required)
Rash?(Required)
Itching/Dry Skin?(Required)
Growths/Lesions?(Required)
Laceration?(Required)

NEUROLOGIC:

Loss of Consciousness?(Required)
Weakness/Numbness?(Required)
Seizures/Dizziness?(Required)
Frequent/Severe Headaches?(Required)
Restless Legs/Tremor?(Required)
Migraines?(Required)

CARDIOVASCULAR:

Chest Pain?(Required)
Shortness of Breath?(Required)
Palpitations?(Required)
Arm Pain?(Required)
Heart Murmur?(Required)
Light-headed?(Required)

PSYCHIATRIC:

Depression/Anxiety?(Required)
Restless Sleep?(Required)
Alcohol Abuse?(Required)
Sleep Disturbances?(Required)
Suicidal Thoughts?(Required)
Hallucinations?(Required)

RESPIRATORY:

Cough?(Required)
Shortness of Breath?(Required)
Wheezing?(Required)
Coughing up Blood?(Required)
Sleep Apnea?(Required)

ENDOCRINE:

Fatigue?(Required)
Increased Thirst?(Required)
Hair Loss?(Required)
Cold Intolerance?(Required)
Increased Hair Growth?(Required)

GASTROINTESTINAL:

Abdominal Pain?(Required)
Vomiting?(Required)
Change in Appetite?(Required)
Black/Tarn/ Stools?(Required)
Frequent Diarrhea?(Required)
Dyspepsia?(Required)
GERD?(Required)
Vomiting Blood?(Required)

HEMATOLOGIC/LYMPHATIC:

Swollen Glands?(Required)
Easy Bruising?(Required)
Excessive Bleeding?(Required)

ALLERIC/IMMUNOLOGIC:

Runny Nose?(Required)
Sinus Pressure?(Required)
Itching?(Required)
Hives?(Required)
Frequent Sneezing?(Required)

Request for Release of Protected Health Information (HIPPA):

This form will be used to release your protected health information as required by federal and state privacy laws Your authorization allows Paradigm Hormones to release your protected health information to a person or organization that you choose. You can revoke this authorization at any time by submitting a request in writing to Paradigm Hormones. Revoking this authorization will not affect any action taken prior to receipt of your written request.

Your Information:

Name:(Required)
Address:(Required)
MM slash DD slash YYYY

I authorize my physicians, medical professionals, Paradigm Hormones, and its agents/affiliates to release my protected health information as described below:

Recipient:
Manner of Release:(Required)
Description of Information to be Released:(Required)
This authorization will expire (please check one of the following):(Required)

"l affirm all the information supplied is true and correct. further understand that this authorization to release information is voluntary and is not a condition of treatment, eligibility for benefits, or payment or claims. also understand that if the person or organization I authorize to receive the information described above is not subject to federal health information privacy laws, they may further release the protected health information and it may no longer be protected by federal privacy laws. I request that Paradigm Hormones release the protected health information described above to the persons and/or entities listed above for the purposes set forth above.

MM slash DD slash YYYY

CO-PAY / DEDUCTABLE/ CO INSURANCE NOTICE:

Financial agreement: Payment of all copays, deductibles, and/or coinsurance are due at the time Of service. As a service to you, our office will bill your insurance company if you desire. Being a participating provider with most insurance companies, the insurance companies require that we collect these fees, as they are terms of your health care contract. Additionally, patients are ultimately responsible for all balances.
If your deductible HAS been met, you will only be responsible for your copay and any coinsurance your insurance requires. (unless your out-of-pocket has been met for the year.)
If your deductible HAS NOT been met, Paradigm will apply your insurance's contracted amount and you will be responsible for 100% of amount due at the time of service.
All self pay patients are 100% responsible for every visit for the agreed upon amount with the billing department-
Payment policy: Payment is expected at the time the services are rendered. For your convince we accept cash, Visa, Mastercard, American Express and Debit cards. Arrangements must be made for the payment of any balance greater than $200.

MM slash DD slash YYYY

Prescription Policy: Paradigm diagnosis and treats hormonal conditions. These medications when properly used can help patients feel better and lead more productive lives. Our policy;
1. Written prescriptions will NOT be replaced if lost, stolen or misplaced
2. Prescriptions are to be taken as directed. DO NOT change the frequency of the dose unless otherwise directed by a Paradigm professional. If a change does occur it will be documented in your chart.
3. Refills of prescriptions may be refilled every 3 months. If you have not been seen in those 3 months we have the right to refuse refills until you are seen by Paradigm staff.
4. Refills will NOT be authorized at night, on weekends, or holidays. Be sure to plan ahead to make sure you have enough to last you.
5. Prescription requests before noon will be available at your pharmacy after 5pm that day. Requests made after 12 noon will be available at your pharmacy the following morning

Consent to Have Blood Drawn:
MM slash DD slash YYYY
Patient Acknowledgement Of Receipt of Notice of Privacy Practices:(Required)
MM slash DD slash YYYY
Consent to Order Medical/prescription History :(Required)
MM slash DD slash YYYY
Consent to Contact:(Required)
MM slash DD slash YYYY
Girl in a jacket

Cancellation Policy

Your appointments and well-being are very important to us. We understand that sometimes unexpected delays can Occur. If you need to cancel your appointment, we respectfully request at least 24 hour notice.
Any cancellation or rescheduled appointment made less than 24 hours will result in a cancellation fee of $25.
If you are more than 10 minutes late for your appointment, we May not be able to accommodate you. We will do our very best to reschedule your appointment for another time that is convenient to you.
Please understand that appointment times are limited. We know your time is valuable, and Ours is too. Out of respect for our staff and our other patients, we ask that you give us at least 24 hour notice if you need to cancel an appointment.
The first time an appointment is missed, we will make a note in your file.
All future missed appointments will incur a $25 fee.

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Copyright © Paradigm Hormones Restorative Care | All Rights Reserved
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