1580 Montgomery Hwy STE 14-B | Hoover, AL 35216

(205) 352-9141

Patient Information

First Name *
Last Name *
Email *
Contact Number *
Address *
City *
State *
ZIP Code *
Date of Birth *
Goal Weight *
Blood Pressure *
Age *
Height *
Marital Status
Sex *
Occupation *
Type "N/A" if blank
Alcohol Use *
Current Weight *
Driver License # *
Tobacco Use *
Emergency Contact First Name *
Last Name *
Emergency Contact Phone *
Relationship *
Primary Physician *
Do you have insurance? *
List insurance provider *
Any medical allergies? *
Please list all known allergies *
Please list current symptoms & concerns prompting your visit. *
List any major hospitalization, operations, or illness. *
List current Rx medications taken in the past 6 months *
Personal & Family History
Check all symptoms you have experienced in the last 6 months
*
Abnormal Blood Pressure *
Blood Disorder/Anemia *
Depression/Mental Illness *
Epilepsy *
Herpes/Cold Sores *
HPV/Human Papillomavirus *
Emphysema *
Pneumonia *
Thyroid Disease *
Ulcers *
Arthritis or Joint Problems *
Cancer/Tumor/Cysts *
Diabetes *
Excessive Bleeding *
High Cholesterol *
Jaundice/Liver Disease *
Melanoma/Skin Cancer *
Recurring Infections *
Tuberculosis *
Asthma Bronchitis *
Colitis *
Eczema/Psoriasis *
Gallstones *
HIV/AIDS *
Keloid Scarring *
Parasites *
Rheumatic Fever *
Seizures *
Autoimmune Disease *
Crohn's Disease *
Endocrine Disorder *
Heart Disease *
Hepatitis *
Kidney Infection/Stones *
Varicose Veins *
Rheumatoid Arthritis *
Stroke *
SCORE EACH FROM 0 -10, WITH 10 BEING HIGHEST:
Current Level of Back Pain *
Evening Energy Level *
Current Level of Joint Pain *
Stress Level Past 6 Months *
Morning Energy Level *
Stress Level Past 3 Days *
Integrative Chiropractic Symptom Analysis
In an effort to provide you with complete and overall wellness care, we would like to invite you to share the following information so that Dr. Russell can assist you with any additional symptoms or conditions you might be facing.
Have you suffered from any of the following symptoms/conditions in the pas 6 months (check all that apply). *

Hormone Optimization Therapy Questionnaire

ADAM questionnaire about symptoms of low testosterone (Androgen Deficiency in the Aging Male) The basic questioner can be very useful for men to describe the kind and severity of their low testosterone one symptoms.

Do you regularly experience poor sleep? *
Have you recently experienced weight gain? *
Are your erections less strong? *
Do you regularly experience “brain fog”? *
How many cups of coffee/energy drinks/caffeine do you drink each day? *
Have you constantly tired and lacking energy? *
Have you lost height? *
Have you noticed a recent deterioration in your work performance? *
Have you noticed a decreased “enjoyment of life” ? *
Do you regularly experience stomach or other gut related issues like bloating, gas, or irregular bowel movements? *
Are you experiencing thinning or increased shedding of hair? *
Are you usually anxious and have a hard time relaxing? *
Are you sad or grumpy? *
Do you get yeast infections or crave sugars? *
Do you have a decrease in libido (sex drive)? *
Do you often feel cold when those around you don’t? *
Do you have a decrease in strength and/ or endurance? *

If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.

Telltale Symptoms of Hormonal Imbalance in Women (HIMB) This basic questionnaire can be very useful for women to describe the kind and severity of their low estrogen symptoms.

Irregular Periods *
Depression/Irritability *
Breast Changes *
Sleep Issues *
Weight Gain *
Night Sweats *
Stomach Issues *
Headaches *
Extreme Fatigue *
Lowered Libido *

SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY

Irregular Cycles *
Swollen Belly *
Increased Belly Fat *
Painful Intercourse *
Loss of Self Control *
Weight Gain *
Light Menstrual Flow *
Loss of Muscle Tone *
Cramped *
Painful Periods *
Memory Lapse/Mental Fog *
Depression *
Swollen Tender Breasts *
Vaginal Dryness *
Heavy Periods *
Reduced Libido *
Hair Loss on Crown *
Anxious *
Wrinkled/Slacked Face *
Irritable and Aggressive Behavior *
Fatigued/Exhausted *
Hot Flashes *
Restless/Light Sleep *

This agreement between ("Patient'') and Vital Force Therapy & Wellness. Vital Force and patient agree that these guidelines and conditions are an essential factor In maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore. these agents are prescribed with caution. The patient agrees and accepts to the following conditions:

I understand that the Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions In accordance with applicable state and Federal law.

I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.

I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.

I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effect related to my treatment to Vital Force Therapy & Wellness and discontinue use until advised to resume usage by my health care provider.

I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.

I understand that representatives of Vital Force Therapy & Wellness and/or Licensed Physicians Assistant are available 'for questions and/or. concerning during normal business hours throughout the course of my treatment.

I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by Vital Force Therapy & Wellness or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party payer.

I agree that the Vital Force Therapy & Wellness/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Vital Force Therapy & Wellness will be in conjunction with the care provided by my current PCP.

I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled container.

I have read and agree to the terms of this the Therapy Management Agreement.

I consent to text message appointment reminders. (Data rates may apply)

This agreement between ("Patient") and Vital Force Therapy & Wellness lounge establishes guidelines and conditions for the use of hormone replacement therapy ("HRT") involving DEA "controlled" or "scheduled" medications. PP and patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with caution. The patient agrees and accepts to the following conditions:

I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my submitted medical history, and the results of lab work and a physical examination. The medications are to be used exclusively for treatment of hormonal deficiencies and related medical conditions in accordance with applicable state and Federal law.

I understand and agree that no medical treatment or medication provided to me by Vital Force will be used for the purposes of bodybuilding, performance enhancement or physical appearance.

I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.

I will not attempt to obtain HRT medications from any other health care practitioner without disclosing my current medical usage of HRT or other medications. I understand that it may be against the law to do so.

I have discussed and understand the risks and benefits associated with HRT. I will immediately report any adverse side effect related to the use of my HRT to Vital Force Therapy & Wellness and discontinue use until advised to resume usage by Progressive Health Institute. I voluntarily assume any and all possible risks which may be associated with HRT.

I understand that representatives of Vital Force Therapy & Wellness and/or licensed Physicians Assistant are available for questions and/or concerning during normal business hours throughout the course of my treatment.

I agree that the HRT medications furnished by Vital Force Therapy & Wellness are for my personal use only and for no other purpose. I will not share, sell. or trade my medications. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.

I will be able to purchase the medications from the pharmacy designated by Vital Force Therapy & Wellness and the pharmacy will send medication directly to me. I understand I have the right to purchase my medications from any pharmacy of my choice.

If I chose to obtain medications from a pharmacy of my own choice, I must notify Vital Force Therapy & Wellness in writing of my intention to do so and include the name of the pharmacy in my request.

I agree and understand that federal regulations prohibit the return of prescribed medications.

I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by Vital Force Therapy & Wellness or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party payer.

I agree that the Vital Force Therapy & Wellness patient/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Vital Force Therapy & Wellness will be in conjunction with the care provided by my current PCP.

I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.

I understand that Vital Force Therapy & Wellness only treats patients over the age of 30 with documented symptoms of hormone deficiencies (Hypogonadism and Adult Growth Hormone Deficiency). No prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current health history through either patient's personal physician or a Progressive Health Institute - affiliated physician. Agreeing to lab work does not automatically qualify patient to clinically necessity and prescription of HRT.

I understand that should I choose to opt out of therapy with Vital Force Therapy & Wellness, all of my prescriptions will be cancelled through the pharmacy and will not be transferred to any other pharmacy.
This Therapy Management Agreement is a binding contract for a minimum of 3 consecutive months. If you choose to cancel your membership prior to the 3 month commitment you will be responsible for the payment of the remainder of your 3 month commitment. (IE: Used HRT 1 month, then cancel - responsible for 2 remaining months).

I consent to text message appointment reminders. (Data rates may apply)

I have read and fully understand clause #1 through #15 on this agreement and by signing below I agree that Vital Force Therapy & Wellness has permission to charge my account, should I choose to opt out of the Hormone Replacement Therapy Program, I acknowledge my card will be charged the full three month amount accordingly.

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