MEDICAL HISTORY AND SCREENING FORM General InformationLocationViking Location*VIKING ALTERNATIVE MEDICINE - CORPORATEViking Chesterfield -132 Chesterfield Town Centre, Chesterfield MO 63005TriMax Health and FitnessReferral ID ParticipantFull Name ( Legal name)* First Middle Last Preferred Name (if different from above)Date of Birth* Date Format: MM slash DD slash YYYY Email* Phone*Alternate NumberAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about Viking Alternative Medicine?How did you hear about PureHRT?Ethnicity American Indian Alaskan Native Black or African American Hispanic or Latino Asian White Native Hawaiian or Pacific Islander Patient Declined Other OtherMarital StatusSingleMarriedDivorcedWidowedSex*MaleFemalePurposeWhat is/are your purpose(s) for participating in the HRT program? To determine my current level of health and to receive a possible recommendation. Other Other PurposeCurrent Medical HistoryMedical history checkboxesCheck those questions to which you answer yes. Leave all others blank. Has a doctor ever said your blood pressure was too high? Do you ever have pain in your chest or heart? Are you often bothered by a thumping of the heart? Does your heart often race? Do you ever notice extra heartbeats or skipped beats? Are your ankles often abnormally swollen? Do cold hands or feet trouble you even in hot weather? Has a doctor ever said that you have had heart trouble, an abnormal echocardiogram or EKG, heart attack or coronary? Do you suffer from frequent cramps in your legs? Do you often have difficulty breathing? Do you get out of breath long before anyone else? Do you sometimes get out of breath when sitting or sleeping? Has a doctor ever told you that your cholesterol level was high? Has a doctor ever told you that you have an abdominal aortic aneurism? Has a doctor ever told you that you have a critical aortic stenosis? None of the above Comments:Do you now have or have you recently experienced? chronic, recurrent or morning cough? episodes of coughing up blood? increased anxiety or depression? Problems with recurrent fatigue, trouble sleeping or increased irritability? migraine or recurrent headaches? swollen or painful knees or ankles? swollen, stiff or painful joints? pain in your legs after walking short distances? foot problems? back problems? stomach or intestinal problems such as recurrent heartburn, ulcers, constipation or diarrhea? significant vision or hearing problems? recent change in a wart or mole? glaucoma or increased pressure in the eyes? exposure to long noises for long periods? an infection such as pneumonia followed by fever? significant unexplained weight loss? a fever which can cause dehydration and rapid heartbeat? a deep vein thrombosis (blood clot)? a hernia that is causing symptoms? foot or ankle sores that won’t heal? persistent pain or problems walking after you have fallen? eye symptoms such as bleeding the retina or detached retina? cataract or lens transplant? laser treatment or another eye surgery? None Comments:Women only answer the following:Do you have? menstrual period problems? significant childbirth related problems? urine loss when you cough, sneeze or laugh? Date of last pelvic exam and/or PAP smear: Date Format: MM slash DD slash YYYY Are you on any type of hormone replacement therapy?YesNoComments:Men and Women, both, answer the following:List any prescription medications you are now taking:List any self-prescribed medications, dietary supplements or vitamins you are now taking:Date of last complete physical examination: Date Format: MM slash DD slash YYYY Last Physical exam results Normal Abnormal Never Can't Remember Date of last chest x-ray: Date Format: MM slash DD slash YYYY Chest x-ray results Normal Abnormal Never Can't Remember Date of last echocardiogram (EKG or ECG): Date Format: MM slash DD slash YYYY EKG Results Normal Abnormal Never Can't Remember Date of last dental exam: Date Format: MM slash DD slash YYYY Dental Results Normal Abnormal Never Can't Remember List any medical or diagnostic testing you have had in the last two years:List hospitalizations including dates of and reasons for hospitalizations:List all allergies to drugs:Past Medical HistoryCheck those questions to which you answer yes. Leave all others blank. Heart attack Heart murmur Varicose veins Diabetes or abnormal blood sugar tests Dizziness or fainting spells Stroke Scarlet fever Infectious mononucleosis Thyroid problems Pneumonia Asthma Other lung disease Bronchitis Jaundice or gallbladder problems Rheumatic fever Diseases of the arteries Arthritis of the legs or arms Phlebitis (inflammation of a vein) Epilepsy or seizures Diphtheria Nervous or emotional problems Anemia Abnormal chest x-ray Injuries to back, legs, arms or joints Broken bones none Comments:Note: include heart attack date.We will need a copy of your current bloodwork and your drivers license prior to ordering medication. If you have them handy, please submit them here, otherwise please continue with the form.Please upload a copy of your Driver License Drop files here or Accepted file types: jpg, jpeg, png, pdf. Please upload a copy of your most recent Laboratory Results Drop files here or Accepted file types: jpg, jpeg, png, pdf. Patient Authorization for Delivery of MedicationsConsent and Authorizations I consent and authorize the the following:I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used. I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. No Guarantee of Services Viking Alternative Medicine 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 Viking Alternative Medicine. No Refund Policy *Viking Alternative Medicine reserves the right to have NO RETURN and NO REFUND policy.Consent and Authorizations I consent and authorize the the following:I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used. I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. No Guarantee of Services Viking Alternative Medicine 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 PureHRT. No Refund Policy *PureHRT reserves the right to have NO RETURN and NO REFUND policy.Name First Middle Last Informed Consent for Hormone Replacement TherapyInformed Consent for Hormone Replacement Therapy I agree to the Hormone Replacement Therapy policy.Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. 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 doctor. When hormone levels are brought back to “normal” for your age there is much evidence that your overall health will benefit. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment. The medical frame of mind is always changing so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest information is. Please read the following and sign: I have discussed the reason for taking female/male sex hormones with my provider. I understand why he/she is prescribing them and the risks associated with taking hormones including but 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 risks if I take any HRT medication. I have discussed these risks and the reasons for taking them, with my doctor. I understand that my provider will do everything he/she knows 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 or 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 for me.Name First Middle Last OPTIONAL Credit Card Authorization FormCredit Card Type Master Card Visa Discover Amex Credit Card NumberExpiration Datemm/yyyySecurity CodeName on Card First Middle Last Billing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card Policy I agree to the credit card policy policy.By signing this form, you give PureHRT permission to keep the above credit card on file and charge it for future orders. The card on file can be changed prior to your next transaction. You are authorizing PureHRT to charge and sign your card for future transactions *** PureHRT reserves the right to have a NO RETURN AND NO REFUND POLICY.***Credit Card Policy I agree to the credit card policy policy.By signing this form, you give Viking Alternative Medicine permission to keep the above credit card on file and charge it for future orders. The card on file can be changed prior to your next transaction. You are authorizing Viking Alternative Medicine to charge and sign your card for future transactions *** Viking Alternative Medicine reserves the right to have a NO RETURN AND NO REFUND POLICY.***