(602) 716-9000 ViTal4Men, PLLC Donald Middleton D.O.Peoria Chandler Mesa/Gilbert

7707 W Deer Valley Rd. Ste 115 655 S Dobson Rd. Ste B216 4140 E. Baseline Rd. Ste 111Peoria, AZ 85382 Chandler, AZ 85224 Mesa, AZ 85206

PATIENT INFORMATION

__________________________________________________ ___________________________

Patient Name Date

________________________________________________________________ ____________ _____ _____________

Street address City State ZIP Code

_________________________________ ________________________________

Cell phone number Home phone number

Is it ok to leave a message on your voicemail with relevant clinical information? Yes _____ No _____ DOB:___________________________

Ethnicity: Hispanic:____ Caucasian:____ African-American:____ Asian:____ Other:____ Occupation:_____________________________

We can contact you via text or email with important clinical reminders. You will not receive spam messages.Please select the check box next to your preference.

Text: (Please print cell service provider): (Please print cell number):

Email: (Please print email address):

I want to be contacted by both Text & Email: (Please fill out the two boxes above)

Please Do Not Contact Me

How did you hear about us? 620AM ESPN Sports Radio

Internet/Vital4men Website Sign

100.7 FM KSLX Classic Rock Dr. Referral:

92.3 FM News Radio Friend Referral:

98.7 FM Sports Radio Other:

Insurance Information

Are you currently covered by Health Insurance: Yes / No (circle one)

Insurance Company:_________________________ Policy Holders Name:___________________________

Policy ID#:______________________________ Group #:_____________________________

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Release of Medical Information

I ___________________________________, give permission for my health care information to be disclosed for the purposes of communicating resultsand findings to the family members below. Per HIPAA regulations we cannot release any information to individuals not listed below.

Name of Authorized Individuals Relationship to Patient DOB (for security)

1. ________________________________________ ________________________________ ___________________________

2. ________________________________________ ________________________________ ___________________________

3. ________________________________________ ________________________________ ___________________________

___________________________________________ _______________________________ ____/_____/_____

Print Name Signature Date

Name (Last, First, M.I.): Male Female DOB:

Marital status: Single Partnered Married Separated Divorced Widowed

Previous or referring doctor: Date of last physical exam:

Please check all that apply. Also, list any other problems that doctors have diagnosed.

Anxiety Disorder Dialysis High Cholesterol Reflux or Ulcers

Arthritis Diverticulitis High Blood Pressure Sleep apnea

Asthma Enlarged Prostate Kidney Disease Stroke

Bleeding Disorder Fibromyalgia Kidney Stones Tuberculosis

Blood Clots (or DVT) Gout Leg/Foot Ulcers Vascular Disease

Cancer Has Pacemaker Liver Disease Other (Please list)

Coronary Artery Disease Heart Attack Osteoporosis

Claustrophobic Heart Murmur or Arrhythmia Overactive thyroid

Depressive Disorder Hepatitis C Underactive thyroid

Diabetes - Insulin Hiatal Hernia Polio

Diabetes - Non-Insulin HIV or AIDS Pulmonary Embolism

Surgeries/Procedures

Year Reason Hospital

Other hospitalizations requiring admission with overnight stays

Year Reason Hospital

Have you ever had a blood transfusion? Yes No

Allergies. List anything that you are allergic to (medications, food, bee stings, etc) and how each affects you.

Allergy Reaction

List your prescribed medications, as well as over-the-counter medications such as vitamins and inhalers.

Medication Strength Frequency Taken

ViTal4Men ChandlerViTal4Men Peoria7707 W Deer Valley Rd. Ste 115

Peoria, AZ 85382

ViTal4Men Mesa/Gilbert4140 E. Baseline Rd. Ste 111

Mesa, AZ 85206

PAST MEDICAL HISTORY

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

HEALTH HISTORY QUESTIONNAIRE

655 S Dobson Rd. Ste 216, Bld B

Chandler, AZ 85225

Exercise Sedentary (No exercise)

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4 x/week for 30 minutes)

Regular vigorous exercise (i.e., work or recreation 4 x/week for 30 minutes)

Diet Are you dieting? Yes No

If yes, do you follow a specific diet? Yes No

If yes, are you on a physician prescribed medical diet? Yes No

How many meals do you eat in an average day?

Caffeine None Coffee Tea Soda Energy Drinks

If yes, how many caffeinated drinks do you have per day?

Alcohol Do you drink alcohol? Yes No

If yes, how many alcoholic drinks do you have per week, on average?

Tobacco Do you use tobacco? Yes No

If yes, which version do you use, and what quantity do you use per day?

Cigarettes - packs/day Chew - #/day Cigars - #/day Pipe - #/day

If you do not use tobacco, are you a former tobacco user? Yes No

If you are a former tobacco user, when did you quit?

Drugs Do you currently use recreational drugs? Yes No

Do you have a history of recreation drug use? Yes No

Have you ever used testosterone or any other anabolic steroids? Yes No

If you have used testosterone or any other anabolics, was it prescribed by a doctor? Yes No

If you have used testosterone or any other anabolics, please list types and dates of use on the next line.

Sex Are you sexually active? This includes with your spouse or significant other. Yes No

If yes, are you trying for a pregnancy? Yes No

Please fill out information for biological relatives. If no health problems exist, please mark "N/A" in the Health History section.

Yes No, Age at death______

Yes No, Age at death______

Siblings Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Brother Sister Yes No, Age at death______

Children Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Daughter Son Yes No, Age at death______

Mother

Father

SOCIAL HISTORY

Living? Health History

FAMILY MEDICAL HISTORY

Relation

Check if you have any symptoms in the following areas and briefly explain.

Skin

Head/Neck

Eyes

Ears

Nose

Throat

Chest/Heart

Back

Bowel/Intestinal

Bladder

Check if you have any of the following past medical history:

History of kidney, bladder or prostate infections.

History of testicular trauma. If box is checked, please explain.

History of head trauma. If box is checked, please explain.

History of coronary artery disease (CAD) or vascular disease.

History of referral to a Cardiologist. If box is checked, please explain.

History of prostate and/or rectal exam. If box is checked, what was the date?

Check if you have any of the following symptoms:

Fatigue/decrease in energy level.

Unintentional weight gain, ______ lbs in ______ months.

Unintentional weight loss, ______ lbs in ______ months.

Difficulty falling asleep or staying asleep.

Decreased libido.

Difficulty with erection or erectile dysfunction.

Decrease in strength/increase in recovery time/decrease in exercise capacity.

Waking up at night to urinate. If box is checked, how many times per night? ______

Pain or burning with urination.

Blood in your urine.

Difficulty emptying your bladder completely.

Depressed mood.

Stress or feelings of anxiety.

Irritability or moodiness.

Decreased mental focus.

Decrease in sense of well being.

Other

/ /

Print Name Signature Date

TRT SPECIFIC

REVIEW OF SYSTEMS

Cancer Risk Assessment Questionnaire

Patient Name:Date of Birth: Today’s Date:

Are you of Ashkenazi Jewish (Eastern European Descent) – Important for genetic screening Y / N

Have you ever been tested for a Hereditary Cancer Syndrome (e.g. BRCA or Lynch Syndrome) Y / N

If Yes, please specify: __________________________

Patient Signature ____________________ Date _______________ MD Signature____________________ Date_________________

MEDICAL & CANCER HISTORYPlease list every relative who has had one of the following

conditionsSELF

FAMILY MEMBER

MOTHER’S SIDEAGE at Diagnosis

FATHER’S SIDEAGE at Diagnosis

Y N EXAMPLE: Breast CancerAunt - age 45Cousin - age 61

Grandmother - age53

Y N Breast Cancer

Y NAnyone with Breast cancer in both breasts or in the

same breast 2x (list ages at time of diagnosis)

Y N Male breast cancer at any age

Y N Triple negative breast cancer (ER-, PR-, HER2-)

Y NOvarian Cancer

Y NPancreatic cancer

Y N Prostate cancer

Y NAny other cancers (please list with as much detail as

possible)

Your Personal & Family History is Important to UsWe NEED this information to perform an accurate assessment of your medical & cancer risks

Instructions: When you circle Y, provide the age of diagnosis and relationship of family member with the illness/cancer.

Please include all relatives up to your great-grandparents (including siblings, aunts / uncles, cousins, nieces / nephews, grandparents)

Knowing your family history can save your life!Use your next family gathering to actively collect and share family history with your relatives.

Vital4Men Clinic

Vital4Men ClinicTestosterone Consent Form & Terms of Acceptance

At the Vital4Men Clinic, our goals of treatment are to help treat hypogonadism (low testosterone)and restore your testosterone level to the upper range of normal as well as improve your overallquality of life. The American Academy of Family Physicians has examined the effectiveness &safety of testosterone replacement therapy (TRT) and found that there is no compelling evidenceof major side effects of properly administered TRT.

However rare side effects sometimes occur. TRT side effects can include the following:

Cardiac: One study with results published in January 2014, showed an increased risk of MI inpatients over the age of 65 and in younger men with pre-existing diagnosed heart disease,following initiation of TRT. Further evaluation of this and other published reports indicates cardiacside effects can be mitigated and controlled with proper screening and selection of appropriatepatients, as well as proper supervision & administration of TRT.

Fluid Retention: Fluid accumulation may be observed, especially in older men. Symptoms mayinclude leg or ankle swelling, worsening of congestive heart failure, or high blood pressure.

Elevation in Red Blood Cells/Hemoglobin/Hematocrit: TRT may cause an increase in redblood cell concentration, hemoglobin and hematocrit levels.

Breast Tissue Enlargement: This is the result of testosterone converting into estrogen. Thisside effect can be controlled via a variety of methods.

Prostate EnlargementChanges in Lipid & Cholesterol LevelsAcne and/or Oily SkinTesticular AtrophyDecreased Fertility

_________ All of the above conditions have been fully disclosed & explained by(patient initial) my Vital4Men Provider.

_________ I have had the opportunity to discuss in detail my health history with(patient initial) my Vital4Men Provider.

_________ I understand that Vital4Men recommends an annual physical(patient initial) examination.

_________ I understand that medicine is an art, not an exact science and that(patient initial) diagnosis and treatment may involve injury or risks.

_______________________________ _______________________________ ___/___/___

Print Name Signature Date

ViTal4Men Clinic

HIPAA – Notice of Privacy Practices

The Vital4Men Clinic is required by law to maintain the privacy and confidentiality of your protected health information and to provideour patients with notice of our legal duties and privacy practices with respect to your protected health information.

Summary of Rights and Obligations Concerning Health Information.Vital4Men Clinic is committed to preserving the privacy and confidentiality of your health information, which is required both byfederal and state law. We are required by law to provide you with this notice of our legal duties, your rights, and our privacypractices, with respect to using and disclosing your health information that is created or retained by Vital4Men. Each time you visitus, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, our assessment ofyour condition, a record of your treatment interventions, and a plan for future care or treatment. We have an ethical and legalobligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances.In general, we may use and disclose your health information to:

• plan your care and treatment;• provide treatment by us or others;• communicate with other providers such as referring physicians;• receive payment from you, your health plan, or your health insurer;• make quality assessments and work to improve the care we render and the outcomes weachieve, known as health care operations;

• make you aware of services and treatments that may be of interest to you; and• comply with state and federal laws that require us to disclose your health information.

We may also use or disclose your health information where you have authorized us to do so.

You have the right to:• ensure the accuracy of your health record;• request confidential communications between you and your therapist and request limits on theuse and disclosure of your health information; and

• request an accounting of certain uses and disclosures of health information we have madeabout you.

We are required to:• maintain the privacy of your health information;• provide you with notice, such as this Notice of Privacy Practices, as to our legal duties andprivacy practices with respect to information we collect and maintain about you;

• abide by the terms of our most current Notice of Privacy Practices;• notify you if we are unable to agree to a requested restriction; and• accommodate reasonable requests you may have to communicate healthinformation by alternative means or at alternative locations.

Disclosure of Your Health Care Information:

We may disclose your healthcare information as necessary to comply with State Workers Compensation laws, Public HealthAuthorities, Emergency Situations, Judicial & Administrative Proceedings, Law Enforcement, Medical Examiners, Researcher thathas been approved by an Institutional Review Board, when necessary to prevent a health or safety issue, to military or nationalsecurity and government benefit purposes, for company approved marketing purposes, showing gratitude for referrals, and changeof ownership.

I understand and have been provided with a Notices of Privacy Practices, which provides a description of the information uses anddisclosures. I understand and had the right to review this notice prior to signing the consent, the right to object the use of my healthinformation for directory purposes and the right to request restriction as to how my health information may be used or disclosed tocarry our treatment, payment or healthcare operations.

_______________________________ _______________________________ ___/___/___

Print Name Signature Date

ViTal4Men Clinic

Financial Agreement

I will pay in full for services at the time of my appointment unless I have insurance coverage thatrequires another arrangement, or I make a different agreement with my provider.

Payment for Services:

You are ultimately responsible for payment of services if your insurance carrier does not pay forany reason. IT IS THE RESPONSIBILITY OF THE PATIENT OR THEIR RESPONSIBLEPARTY/REPRESENTATIVE TO KNOW THEIR INSURANCE COVERAGE. Please present yourinsurance card at each visit. Insurance companies deny claims that are not submitted within 90days of the date of service. If you do not submit your current insurance to the office at the time ofyour visit, you may be responsible for denied claims. We attempt to verify coverage before yourvisit with the information you provide. Verification of coverage does not guarantee the insurancecompany will pay for your visit. Insurance policies exclude some non-covered services; however,this does not mean services or tests are not necessary. It means the policy you have does notcover certain necessary services. Please keep in mind your insurance policy is a contractbetween you and the insurance company. The physician has no control over which services theinsurance company does or does not cover.

If your insurance carrier’s “Criteria” for Testosterone Replacement Therapy does not cover orrestricts coverage for services provided by Vital4Men, you will be responsible to arrange paymentfor the specific services that are not covered. We are under contract with your insurance carrierto bill only for services that fall under the “Criteria” of covered benefits. We cannot bill forservices that are deemed “experimental”. In some cases Testosterone Replacement Therapy isconsidered “experimental” by specific insurance companies if the strict “Criteria” is not met.

Current policies in the “ACA” Affordable Care Act may delay payment of your claims due to non-payment of policy premiums by the patient. If your insurance delays, denies or pays and then re-coups the payment of your claims due to non-payment of the policy premium, you will beresponsible to pay the claim in full in accordance with our “Financial Policy” guidelines.

I understand that, if my account is referred to a collection specialist due to non-payment, I will payany applicable collection fees.

INITIALS:

_____I HAVE READ THIS FINANCIAL AGREEMENT, ASKED ANY QUESTIONS I HAVEABOUT IT, AND AGREE TO ITS TERMS.

_________________________________________Patient (Printed)

_________________________________________ _________________________Patient (Signature) Date