NEW PATIENT FORM

6478 Putnam Ford Drive Suite 113 Woodstock, GA 30189

Lead Physician: Dr. Ekan Essien, MD, MPH

Website: Optimalhealthmdcom.net

Office Phone: 678-910-0289

PATIENT INFORMATION

Patient Name:*

Date:

Email:*

DoB *

Sex:

Address:

City:

State:

ZIP:

Phone:

Email Address:

Ethnicity:

Marital Status:

Children(s):

In Case of Emergency Contact:

Emergency Contact Number:

Relationship To You:

How’d You Hear of Us?

REASON FOR VISIT

What Are Your Primary Reasons For Seeking Care at Optimal Health MD?

Hormone Evaluation Testosterone Replacement Therapy Weight Management Peptide Therapy Hormone Testing / Blood Work General Wellness

Other:

Please Describe Your Primary Health Concerns or Goals:

CURRENT SYMPTOMS

When did these symptoms begin?

How Significantly Do These Symptoms Affect Your Daily Life?

Mild Moderate Significant

Current Weight:

Current Height:

Do You Consider Yourself in Good Health?

Any Health Changes Within the Past Year?

Are You Currently Under the Care of a Physician?

MEDICAL HISTORY

Have You Ever Been Diagnosed With or Treated For Any of The Following?

If Yes, Please Explain:

WOMEN ONLY

Could You Possibly Be Pregnant? Date of Last Menstrual Period Date of Last Pap Smear Date of Last Mammogram

MEN ONLY

Date of Last Prostate Exam Date of Last PSA Exam

SURGICAL HISTORY

List Any Previous Surgeries and Approximate Dates:

CURRENT MEDICATIONS

Please List ALL Prescription Medications, Over-The-Counter Medications, Vitamins,
Supplements, Hormones, and Other Products You Currently Use:

MEDICATION/SUPPLEMENT	DOSE	HOW OFTEN

ALLERGIES

Do You Have Any Medication, Food, Or Other Allergies?

No Known Allergies Yes, - Please List:

FAMILY HISTORY

Additional Information:

SOCIAL HISTORY

Do You Currently Smoke or Use Nicotine Products? YES NO

Do You Consume Alcohol? YES NO

Do You Use Recreational Drugs? YES NO

Employer / Occupation:

Exercise Frequency:

RARELY 1-2 DAYS/WEEK 3-4 DAYS/WEEK 5+ DAYS/WEEK

Do You Have Children? YES NO

If Yes, How Many and How Old?

OPTIMAL HEALTH MD NOTICE
OF PRIVACY PRACTICES

BLOOD WORK/ LABORATORY TESTING

I understand that Optimal Health MD may recommend blood testing and laboratory evaluation as part of my medical evaluation and ongoing treatment. I understand that laboratory testing may be recommended before, during, or after treatment depending on my medical history, symptoms, medications, and treatment plan.

COMMUNICATION PREFERENCES

I authorize Optimal Health MD to contact me regarding my care, appointments, scheduling, billing, laboratory results, treatment-related communications, and other healthcare-related matters.

CONSENT TO ANTIBODY TESTING

In the event of an accidental exposure to blood or other bodily fluids through needle stick, cut, mucous membrane contact, or the like, the undersigned consents to appropriate tests for the presence of Hepatitis B & C and HIV, which is the virus believed to cause AIDS. The patient will be informed of any positive results, and all such results will be treated as confidential by Optimal Health MD. There is no charge to the patient.

PATIENT ATTESTATION

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that providing inaccurate or incomplete information may affect my medical evaluation and treatment. I understand that the healthcare provider will determine whether a particular treatment, medication, hormone therapy, weight-management treatment, peptide therapy, or laboratory test is medically appropriate for me.

HIPAA NOTICE & PRIVACY ACKNOWLEDGMENT

I understand that Optimal Health MD is committed to protecting the privacy of my health information in accordance with HIPAA and applicable law. I authorize Optimal Health MD to use and disclose my health information as necessary to provide treatment, process payment, coordinate laboratory testing, and operate the medical practice. I understand that I have the right to access my medical records, request corrections, and ask questions about how my information is used or disclosed.

ACKNOWLEDGMENT

By signing below, I acknowledge that I have read, understand, and agree to the terms of Optimal Health MD's Notice of Privacy Practices.

SIGNATURE OF PATIENT

DATE: