Vital Force Therapy & Wellness Intake Form Please list current symptoms & concerns prompting your visit Additional symptom Additional symptom Additional symptom Additional symptom Additional symptom Patient InformationFIRST NAME MIDDLE NAME LAST NAME NICKNAME ADDRESS CITY STATE ZIP HOME PHONE: MOBILE PHONE: EMAIL ADDRESS: DRIVERS LICENSE NUMBER (copy required on checkin) OCCUPATION: HOURS PER WEEK: REFERRED BY: HEIGHT: WEIGHT: BP If Known BIRTH DATE: AGE: EMERGENCY CONTACT: EMERGENCY CONTACT PHONE NUMBER: RELATIONSHIP: MARITAL STATUS: Married Divorced Widowed Domestic Partnership Single PRIMARY PHYSICIAN: PRIMARY PHYSICIAN'S CLINIC: PRIMARY PHYSICIAN'S ADDRESS: DATE OF LAST VISIT: LIST ANY MAJOR HOSPITALIZATIONS, OPERATIONS OR ILLNESS (INCLUDE WHEN THEY OCCURED & ANY DETAILS):List current Rx Medicines & Used in the past 6 Months (Include Dose, How Often & Reason for Medication)Any Medication Allergies: YES NO IF YES, PLEASE LIST: Tobacco Use: Yes No How Much? Drink Alcohol: Yes No How Much? GENDER*MALEFEMALEPersonal & Family HistoryCheck all symptoms you have experienced in the last 6 months BLOATING, GAS, FLATULENCE HAIR LOSS - FALLING OUT SENSITIVE TO COLD HEARTBURN,REFLUX DRY HAIR PALPITATIONS/FLUTTERS CONSTIPATION THINNING HAIR DIFFICULTY GETTING TO SLEEP HEMORRHOIDS NAUSEA/VOMITING INSOMNIA BOWEL HABIT CHANGES EARS RINGING/DIZZINESS PSORIASIS/ACNE FLAREUPS COUGHING/WHEEZING FATIGUE DRY SKIN FOOD ALLERGIES/INTOLERANCES SEASONAL ALLERGY FEVER TIRED UPON WAKING FRONTAL HEADACHES/SINUSITIS URINARY TRACT INFECTIONS ARTHRITIS/JOINT ACHES & PAINS CRAVINGS - SWEETS COLD HANDS/FEET LOWER BACK PAIN STIFFNISS CRAVINGS -SALT POOR CIRCULATION DEPRESSION WEEPINESS CRAVINGS- BEER WIN LIQUOR PUFFY FACE SWOLLEN EYELIDS IN MORNING ANXIETY IRRITABILITY TEMPER ABNORMAL BLOOD PRESSURE Child Siblings Father Mother Self ARTHRITIS OR JOINT PROBLEMS Child Siblings Father Mother Self ASTHMA BRONCHITIS Child Siblings Father Mother Self AUTOIMMUNE DISEASE Child Siblings Father Mother Self BLOOD DISORDERS/ANEMIA Child Siblings Father Mother Self CANCER/TUMORS/CYSTS Child Siblings Father Mother Self COLITIS Child Siblings Father Mother Self CROHN'S DISEASE Child Siblings Father Mother Self DEPRESSION/MENTAL ILLNESS Child Siblings Father Mother Self DIABETES Child Siblings Father Mother Self ECZEMA/PSORIASIS Child Siblings Father Mother Self ENDOCRINE DISORDER Child Siblings Father Mother Self EPILEPSY Child Siblings Father Mother Self EXCESSIVE BLEEDING Child Siblings Father Mother Self GALLSTONES Child Siblings Father Mother Self HEART DISEASE Child Siblings Father Mother Self HERPES/COLD SORES Child Siblings Father Mother Self HIGH CHOLESTEROL/LIPIDS Child Siblings Father Mother Self HIV Child Siblings Father Mother Self HEPATITIS Child Siblings Father Mother Self HPV/HUMAN PAPILLOMAVIRUS Child Siblings Father Mother Self JAUNDICE/LIVER DISEASE Child Siblings Father Mother Self KELOID SCARRING Child Siblings Father Mother Self KIDNEY INFECTIONS/STONES Child Siblings Father Mother Self EMPHYSEMA Child Siblings Father Mother Self MELANOMA/SKIN CANCER Child Siblings Father Mother Self PARASITES Child Siblings Father Mother Self PHLEBITIS/VARICOSE VEINS Child Siblings Father Mother Self PNEUMONIA Child Siblings Father Mother Self REOCCURRING INFECTIONS Child Siblings Father Mother Self RHEUMATIC FEVER Child Siblings Father Mother Self RHEUMATOID ARTHRITIS Child Siblings Father Mother Self THYROID DISEASE Child Siblings Father Mother Self TUBERCULOSIS Child Siblings Father Mother Self SEIZURES Child Siblings Father Mother Self STROKE Child Siblings Father Mother Self ULCERS Child Siblings Father Mother Self MALE HORMONE 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? Yes No Are you constantly tired and lacking of energy? Yes No Do you regularly experience stomach or other gut related issues like bloating, gas, or irregular bowel movements? Yes No Do you crave sugars? Yes No Have you recently experienced weight gain? Yes No Are you experiencing thinning or increased shedding of hair? Yes No Have you lost height? Yes No Do you have a decrease in libido (sex drive)? Yes No Are your erections less strong? Yes No Have you noticed a recent deterioration in your work performance? Yes No Are you usually anxious and have a hard time relaxing? Yes No Do you often feel cold when those around you don't? Yes No Do you regularly experience "brain fog"? Yes No Have you noticed a decreased “enjoyment of life” ? Yes No Are you sad and/or grumpy? Yes No Do you have a decrease in strength and/ or endurance? Yes No Do you need to consume coffee/energy drinks/caffiene to function? Yes No FEMALE HORMONE QUESTIONNAIRE: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.Do You Currently Have A Monthly Cycle? Yes No Irregular Periods Yes No Sleep Issues Yes No Yeast Infections Yes No Crave Sweet/Sugar? Yes No Stomach Issues Yes No Extreme Fatigue Yes No Depression/Irritability Yes No Weight Gain Yes No Headaches Yes No Lowered Libido Yes No Breast Changes Yes No Night Sweats Yes No SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLYIRREGULAR CYCLES LIGHT MENSTRUAL FLOW SWOLLEN TENDER BREASTS SWOLLEN BELLY LOSS OF MUSCLE TONE VAGINAL DRYNESS IRRITABLE & AGGRESSIVE BEHAVIOR INCREASED BELLY FAT CRAMPS HEAVY PERIODS FATIGUED, FEELING EXHAUSTED PAINFUL INTERCOURSE PAINFUL PERIODS REDUCED LIBIDO HOT FLASHES LOSS OF SELF CONTROL MEMORY LAPSES/MENTAL FOG HAIR LOSS ON TOP OF HEAD RESTLESS, LIGHT SLEEP WEIGHT GAIN DEPRESSION ANXIOUS MEDICAL CONSENT AGREEMENT: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) SignatureDate MM slash DD slash YYYY Marketing AgreementsHere at Vital Force Therapy & Wellness, we like to stay in touch with our current and potential patients via e-mail, text messages, and social media. We would love to have you involved but understand the hesitation. Please read and mark the options below if you are uninterested in these marketing approaches. I would like to OPT OUT of promotional e-mails and text messages. I do NOT agree to having my photo posted on social media for promotional postings.