Secure and Confidential Physician's Quality Of Life Questionnaire
The following form establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" or” scheduled" medications. Patient(s) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician 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.Treatment is for USA Citzens or Residents Only - Over 30 Years Old.
PERSONAL INFORMATION FORM
Name:
Email:
Phone:
Contact Time:
Patient Address:
Street
City United States:
Zip Code: Country (USA Only):
CONFIDENTIAL MEDICAL HISTORY INFORMATION
Date of Birth: / /
Weight: Height:
Gender:    Male    Female
Quality of Life Assessment: Do you have or have your ever had any of the following? If the answer to any is yes, please check and explain below
I have a struggle to finish tasks:
Yes
No
I have to read things several times before they sink in:
Yes
No
I have a difficult time controlling my emotions:
Yes
No
I have to push myself to do things:
Yes
No
I feel worn out even when I haven't done things:
Yes
No
I feel as if I am a burden to people:
Yes
No
I am easily irritated by other people:
Yes
No
I often have to force myselt to stay awak:
Yes
No
I feel a strong need to sleep during the day:
Yes
No
It is difficult for me to make friends:
Yes
No
I often lose track of what I need to say:
Yes
No
I feel like I let people down:
Yes
No
There are times when I feel depressed:
Yes
No
I often forget what people have said to me:
Yes
No
I often feel too tired to do the things I ought to do:
Yes
No
My memory lets me down:
Yes
No
I often feel lonely even when I am with other people:
Yes
No
It takes a lot of effort for me to do simple tasks:
Yes
No
I lack confidence:
Yes
No
I find it hard to mix with people:
Yes
No
I avoid responsibility when possible:
Yes
No
I find it difficult to plan ahead:
Yes
No
I have to force myself to do all of the things that need doing:
Yes
No
Please use this space to explain any positive answers, also please also let us know the best time to contact you.

Please use this space to list any medicines you might be using.

Please use this space to leave any additional comments.

SECTION 5: ELECTRONIC SIGNATURE

This agreement between (patient) and Medical Health establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" or” scheduled" medications. HRT Medical Solutions and (patient) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician 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.

Before submitting, please verify all the information is correct and print this form for your records. Patient agrees and consents to conduct business and transactions with Medical Health by electronic means, Electronic signature confirms authorization and agreement to the terms and conditions referenced above. This form is for pre-qualification only and a hand signed document is required for final approval by our physicians.
Today's Date:  

Patient Signature. Type Your Name:

 (valid electronic signature)

Security Code:

(Please enter 4 digit number on left)

After Checking All Information Above is Correct (Press Right Button):