Intake - Vital Force formerly Revive IV Therapy

FIRST & LAST NAME
NICKNAME
ADDRESS
CITY
STATE
ZIP
CONTACT NUMBER:
DRIVERS LICENSE NUMBER (copy required on checkin)
EMAIL:
OCCUPATION:
HEIGHT:
CURRENT WEIGHT:
GOAL WEIGHT:
BP If Known
BIRTH DATE:
AGE:
EMERGENCY CONTACT:
CONTACT:
RELATIONSHIP:
MARITAL STATUS:
- Married
- Divorced
- Widowed
- Domestic Partnership
- Single

PRIMARY PHYSICIAN:
DATE OF LAST VISIT:
LIST ANY MAJOR HOSPITALIZATIONS, OPERATIONS OR ILLNESS:
List current Rx Medicines & Used in the past 6 Months
Any Medication Allergies:
- YES
- NO
IF YES, PLEASE LIST:
Tobacco Use:
- Yes
- No
How Much?
Drink Alcohol:
- Yes
- No
How Much?
GENDER*
Please list current symptoms & concerns prompting your visit
Symptom/Concern & Date of Onset
Personal & Family History
Check 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
FEMALE HORMONE HISTORY
DATE OF YOUR LAST PERIOD:
ARE YOUR MENSTRUAL CYCLES:
- 21 DAY
- 28 DAY
- IRREGULAR
ARE YOU CURRENTLY PREGNANT:
- YES
- NO
NUMBER OF TOTAL PREGNANCIES:
LIVING:
MISCARRIAGES
LAST DATE OF PAPS SMEAR:
DATE OF LAST MAMMOGRAM:
HAVE YOU EVER USED ORAL CONTRACEPTIVES:
- YES
- NO
BEGAN AT WHAT AGE:
EXPlAIN ANY PROBLEMS WHILE TAKING CONTRACEPTIVES:
AGE STOPPED:
HAVE YOU HAD BREAST CANCER:
- YES
- NO
WHEN:
HAVE YOU HAD OVARIAN CANCER:
- YES
- NO
HAVE YOU HAD OVARIAN CANCER:
- YES
- NO
WHEN:
HAVE YOU HAD FIBROCYSTIC BREASTS:
- YES
- NO
HAVE YOU HAD UTERINE FIBROIDS:
- YES
- NO
HAVE YOU HAD A HYSTERECTOMY:
- YES
- NO
OVARIES REMOVED:
- YES
- NO
TUBIL LIGATION
- YES
- NO
WHAT WAS THE REASON FOR YOUR HYSTERECTOMY:
WHAT WAS THE DATE OF YOUR SURGERY:
HORMONE REPLACEMENT THERAPY 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.
Irregular Periods
- Yes
- No
Sleep Issues
- Yes
- No
Stomach Issues
- Yes
- No
Extreme Fatigue
- Yes
- No
Moody and Blues
- Yes
- No
Weight Gain
- Yes
- No
Headaches
- Yes
- No
Lower Libido
- Yes
- No
Breast Changes
- Yes
- No
Night Sweats
- Yes
- No
HORMONE REPLACEMENT 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 have a decrease in libido (sex drive)?
- Yes
- No
Do you have a lack of energy?
- Yes
- No
Do you have a decrease in strength and/ or endurance?
- Yes
- No
Have you lost height?
- Yes
- No
Have you noticed a decreased “enjoyment of life” ?
- Yes
- No
Are you sad and/or grumpy?
- Yes
- No
Are your erections less strong?
- Yes
- No
Have you noticed a recent deterioration in your work performance?
- Yes
- No
If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.
SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY
IRREGULAR PERIODS
SWOLLEN TENDER BREASTS
FACE IS WRINKLED & SLACK
LIGHT MENSTRUAL FLOW
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 -WAIST, HIPS, THIGHS
DEPRESSED
ANXIOUS
SCORE EACH FROM 0 -10, WITH 10 BEING HIGHEST:
CURRENT LEVEL OF BACK PAIN
STRESS LEVEL PAST 30 DAYS
ENERGY LEVEL IN MORNING
CURRENT LEVEL OF JOINT PAIN
STRESS LEVEL PAST 6 MONTHS
ENERGY LEVEL IN LATE AFTERNOON
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.
SYMPTOM/CONDITIONS*
HAVE YOU SUFFERED FROM ANY OF THE FOLLOWING SYMPTOMS/CONDITIONS IN THE PAST 6 MONTHS (CHECK ALL THAT APPLY TO YOU)
- HEADACHES
- LOW BACK PAIN
- LEG/HIP PAIN
- DIZZINESS
- WRIST PAIN
- MUSCLE SPASMS
- KNEE/ANKLE PAIN
- VISUAL DISTURBANCES
- DIARRHEA/CONSTIPATION
- COLDNESS IN HANDS/FEET
- TMJ/CLICKING/PAIN
- WHIPLASH INJURY
- RECURRENT INFECTIONS
- NECK PAIN
- SHOULDER/ARM/HAND PAIN
- MID BACK/UPPER BACK PAIN
- NAUSEA
- ARTHRITIS
- NUMNESS/TINGLING
- DECREASED RANGE OF MOTION
- MIGRAINE HEADACHES
- WEAKNESS IN GRIP/LEGS
- SHOULDER PAIN
- TRAUMA FROM AUTO ACCIDENT
- ELBOW PAIN
- TRAUMA FROM FALL
INSURANCE COMPANY:
BLOOD PANEL SERVICE
Thank you for choosing the services of Vital Force Anti-Aging (VFAA). An important part of our service is to make sure the costs of patient care are as minimal and affordable as possible.
Payment Options:
VFAA require payment at the time of service. The Lab’ VFAA use will be happy to work with your insurance company to the full benefits of your cover and bill them for the full reimbursement of your treatment. Should your health insurer decline to cover this service we will require payment of up to $250. Please insert below your preferred payment details below:
Name On Card:
Card No:
Exp Date:
CVV/Amex Code:
Signature
Date
MM slash DD slash YYYY
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:
1. 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.
2. 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.
3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
4. 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.
5. I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.
6. 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.
7. 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.
8. 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.
9. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled container.
10. I have read and agree to the terms of this the Therapy Management Agreement.
11. I consent to text message appointment reminders. (Data rates may apply)
Signature
HRT AGREEMENT
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:
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. I agree and understand that federal regulations prohibit the return of prescribed medications.
11. 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.
12. 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.
13. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.
14. 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.
15. I understand that should I choose to opt out of therapy with Vital Force Anti-Aging, all of my prescriptions will be cancelled through the pharmacy and will not be transferred to any other pharmacy.
16. 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).
17. 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.
Signature*
Please sign above with mouse or finger (if tablet)
Date
MM slash DD slash YYYY
Marketing Agreements
Here 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.

Please list current symptoms & concerns prompting your visit

Personal & Family History

FEMALE HORMONE HISTORY

HORMONE REPLACEMENT THERAPY QUESTIONNAIRE:

HORMONE REPLACEMENT THERAPY QUESTIONNAIRE:

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

SCORE EACH FROM 0 -10, WITH 10 BEING HIGHEST:

Integrative Chiropractic Symptom Analysis

BLOOD PANEL SERVICE

MEDICAL CONSENT AGREEMENT:

HRT AGREEMENT

Vital Force (formerly Revive IV Therapy) | Birmingham AL

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205.352.9141

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205.352.9141

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