Medical History Form

Contact Information
Full Name*
Date of Birth*
MM slash DD slash YYYY
Photo ID - Please provide a clear photo of your driver's license*
Max. file size: 64 MB.
Current Address*
Street Address City State ZIP Code
Medical Information
Please provide an emergency contact name and number.
Emergency Contact Full Name*
Emergency Contact Phone Number*
Please provide your primary care physician name and number.
Physician Full Name*
Physician Phone Number*
Do you have any known drug allergies?
Are you currently taking any medications?
Do you have any existing medical problems or conditions?
Have you had any previous surgeries or procedures?
Have you had any problems sleeping?
Have you experienced any decrease in sex drive or libido?
Statement of patient Statement of Patient: I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages. I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing by a Palm Beach Medical or GoHormone provider, my primary care physician, or other specialist. I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as to not being treated. Those risks and potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of and other hormone treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of hormone therapy. I certify this form has been fully explained to me, that I have read it or have had it read to me and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I agree to the therapy described above. I have been educated on the benefits, risks, and possible adverse reactions associated with hormone replacement therapy. I agree all the above health information submitted on the questionnaire is complete and accurate.
Client Full Name*
Client Email Address*
Client Signature*

Medical History Form

Contact Information

Medical Information