Your Medical History

Personal information
First Name*
Last Name*
Email*
SSN*
Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone #
Home
Work
Mobile
Fax
Occupation
Confidential Medical History
Date of Birth*
MM slash DD slash YYYY
Gender*
Height*
Weight*
Primary Physician Information
Physician Name
Physician Phone #
Date of your last physical examination with your physician?
MM slash DD slash YYYY
Primary Physician Information
Please list any surgeries, hospitalizations, diseases, conditions or any other information you feel we should be made aware of:
List all the medications you are taking: Please be specific (Name, dosage, etc.) or specify "none":*
List allergies to any medication:
Do you smoke?
- Yes
- No
If yes, how much do you smoke per day?
Do you drink alcohol?
- Yes
- No
If yes, how much do you drink per week?
Are you taking over the counter supplements?
- Yes
- No
If yes, list name and quantity per day/week
Do you exercise regularly?
- Yes
- No
If yes, please describe activities and time spent exercising
Diagnosed history of disease

Do YOU currently have or ever had any of the following?
Heart Failure / Heart Attack
- Yes
- No
Liver Disease
- Yes
- No
Renal Disease
- Yes
- No
Asthma / COPD
- Yes
- No
Orthopedic or muscle disorder including fracture or joint disorders
- Yes
- No
Allergies to Medications
- Yes
- No
Fibromialgia
- Yes
- No
Anxiety
- Yes
- No
Erectile Dysfunction
- Yes
- No
Back Problems / Injury
- Yes
- No
Diabetes
- Yes
- No
Hypertension
- Yes
- No
Cancer
- Yes
- No
Cholestrol Problems
- Yes
- No
Anemia
- Yes
- No
Thyroid Problems
- Yes
- No
Prospective Patients

Please check the symptoms you hope to have improved through hormone replacement therapy (HRT). VITALITY HEALTH AND ITS PHYSICIANS DO NOT TREAT PATIENTS FOR ATHLETIC PERFORMANCE OR ENHANCEMENT

Existing Patients

Please check the symptoms you have improved and hope to continue to improve through HRT.
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
Cold or heat intolerance
- Yes
- No
Increasingly stressed
- Yes
- No
Loss of interest in sex/low Libido
- Yes
- No
Decreasing muscle strength
- Yes
- No
Loss of concentration, sociability, activity
- Yes
- No
Depression
- Yes
- No
Difficulty sleeping
- Yes
- No
Hot flashes
- Yes
- No
Increasing fat deposits about abdomen and/or thighs
- Yes
- No
Muscle loss
- Yes
- No
Thinning or loss of hair
- Yes
- No
Headaches/ Migraines
- Yes
- No
Weight loss – Unexplained
- Yes
- No
Currently Pregnant?
- Yes
- No
Other
- Yes
- No
Please use this space to explain other and write any additional information
Family History
Does an IMMEDIATE FAMILY MEMBER currently have or ever had any of the following? If yes, please check and explain below:
Heart Disease
- Yes
- No
Diabetes
- Yes
- No
Thyroid Problems
- Yes
- No
High Blood Pressure
- Yes
- No
Cholesterol Problems
- Yes
- No
Cancer
- Yes
- No
Osteoporosis
- Yes
- No
Anemia
- Yes
- No
Please use this space to explain any Yes answer and write any additional information regarding any of the above medical condition(s) that an IMMEDIATE FAMILY MEMBER may have, or have had:
Signature
Patient’s Agreement and Release
THIS AGREEMENT is made and executed on the May 30, 2019, between Andrologix Health and Wellness, LLC. (hereinafter referred to as "Andrologix") and ________ (hereinafter referred to as "Patient"*
Fill in this field with your name
IN CONSIDERATION of the Andrologix Health and Wellness, LLC., providing Patient with medical management, administrative and referral services, Patient acknowledges, understands and agrees to the following terms and conditions as set forth herein. MEDICAL HISTORY FORM: Patient will submit an accurately completed Medical History Form. Patient agrees to truthfully, accurately and completely respond in completing this form and acknowledges, understands and agrees that failure to provide truthful, accurate and complete information on this form to Andrologix or to the “PHYSICIAN(S)” referred to by Andrologix will result in inappropriate treatment. AUTHORIZATIONS: Patient authorizes Andrologix to obtain on Patient’s behalf medical laboratories, diagnostic testing, Physician(s) and dispensing pharmacies. In addition, Patient authorizes and instructs Andrologix and the Physician(s) referred by Andrologix and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the Medical History Form, laboratory diagnostic tests, and other information submitted to Andrologix under this Agreement. Patient agrees to submit a photo identification for any blood testing pursuant to a Andrologix or Physician(s) test requisition. Patient acknowledges, understands and agrees that laboratory, diagnostic testing services supplied or obtained by Andrologix, and medical services provided to the Patient by Physician(s), are not covered or reimbursed by Medicare or other insurance. PHYSICIAN(s): Patient acknowledges, understands and agrees that Andrologix is a medical management, administration and referral service and does not direct, control or influence the medical treatment decisions made by Physician(s). Patient acknowledges, understands and agrees that Andrologix Advisors are not licensed Physician(s). Patient acknowledges, understands and agrees that Andrologix Physician(s) may not be licensed to practice medicine in Patient’s state or country of residence. MEDICAL CARE SERVICES: Patient further acknowledges, understands and agrees that Andrologix and Physician(s) are rendering the medical care, services and treatment and that Andrologix is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to the Patient by any pharmacy in the State or County of the Patient’s residence. Your prescriptions can be filled at the pharmacy of your choice. If you choose to fill your prescription(s) at Palm Beach Pharmaceuticals, Inc., and have any questions regarding your medications, please feel free to contact our pharmacist at (800) 511-1341, toll-free. Our hours are 9 AM to 5 PM Monday through Friday, 8 AM to 12 PM on Saturday. INSTRUCTIONS AND TREATMENT: Patient acknowledges, understands and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by Physician(s), to immediately cease any medical treatment prescribed by Physician(s) in the event of any adverse reaction or side effect arising from prescribed treatment, and to immediately provide Andrologix and Physician(s) with written notice via facsimile to 561-354-2766 of any such adverse reaction or side affect. Patient acknowledges, understands and agrees that diagnosis and treatment may involve certain risks, including injury. HORMONE REPLACEMENT THERAPY: Patient acknowledges, understands, and agrees that the hormone blood level objective sought as a result of Patient’s hormone replacement therapy, as prescribed by Physician(s), may be at the highest level of a 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 of alternative methods of treatment and the possible consequences and/or complications involved in such hormone replacement treatment. Patient acknowledges, understands and agrees that recombinant human growth hormone replacement therapy involves the use of a medical drug approved for one purpose and are being used for 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(s) to administer such treatment to relieve body ailments and attempt to enhance Patient’s physical condition and health. Patient further acknowledges, understands and agrees that the methods of medical treatment offered by Andrologix and Physician(s) are not accompanied by any claims, guarantees, promises or warranties. PRIMARY-CARE PHYSICIAN: Patient represents that he or she is under the care of a primary-care Physician and that Patient will not rely or substitute the advice of the Andrologix Physician(s) should it conflict with the advice given to Patient by Patient’s primary-care physician. Before taking any medication prescribed by Physician(s), Patient agrees to have a comprehensive physical examination by his or her primary-care physician. Patient agrees to notify his or her primary-care physician and advise such physician that Patient is undergoing hormone replacement therapy. MEDICAL MALPRACTICE INSURANCE: Patient acknowledges, understands and agrees that under Florida law, Physician(s) are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. PHYSICIAN(S) HAVE DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured Physician(s) who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law. PROPRIETARY BUSINESS INFORMATION: During Patient’s relationship with Andrologix and Physician(s), Andrologix and Physician(s) will convey to Patient a range of proprietary business information, including, confidential disclosures and trade secrets’ business practices and Andrologix’s customers and suppliers (“Confidential Information”). No matter how received by Patient during the parties’ relationship. Patient acknowledges, understands and agrees that this Information is confidential, proprietary and uniquely valuable to Andrologix and gravely affects the conduct of business of Andrologix and Andrologix’s goodwill. Patient acknowledges, understands and agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any of Confidential Information or take any action that may result in disclosure of Confidential Information to any third-party person, firm, or business. Patient acknowledges, understands and agrees that if the terms of this paragraph are breached, Andrologix shall be conclusively deemed to be irreparably injured and shall be entitled to an injunction restraining Patient from disclosing any of the Confidential Information and to liquidated damages in the amount of Ten Million Dollars ($10,000,000.00). Patient acknowledges, understands and agrees that the amount of Andrologix’s actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such liquidated damages are not a penalty. JURISDICTION: 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 the State of Florida, 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. WAIVER: Patient acknowledges, understands and agrees that Andrologix is not responsible for the negligent or intentional acts or omissions of any health-care provider or supplier to whom the Patient is referred. The total liability of Andrologix, its officers, directors, employees, agents and stockholders for negligence or intentional acts is limited to the purchase price of any products through Andrologix, Physician(s) or pharmacies, and that Andrologix and Physician(s) will not be liable for any direct, indirect, special, incidental, consequential, or punitive damages. Patient acknowledges, understands and agrees this is a waiver of any and all liability(ies). INDEMNIFICATION: Patient covenants and agrees to indemnify, defend, protect and hold harmless Andrologix and Physician(s) 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, demands, 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, Andrologix 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, acts or omissions of Andrologix or Physician(s), harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Andrologix or Physician(s). Patient is aware of the 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. 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 this 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 has read, understands and agrees to the terms and conditions disclosed herein, including, but not limited to the waiver and indemnification clauses for any liability(ies) arising out of hormone treatment(s) rendered by Andrologix and Physician(s).
Do you agree to the terms and conditions disclosed herein?*
- Yes
- No
Patient Email*
Printed Patient Name*
eSignature*
Date*
MM slash DD slash YYYY