LONGEVITY WELLNESS AND ANTI-AGING INSTITUTE
NEW PATIENT INSTRUCTIONS
Welcome to LWAA:
Congratulations for choosing LONGEVITY WELLNESS AND ANTI-AGING INSTITUTE. We have the world’s most comprehensive evidence-based proactive screening and age management program. We are pleased to have you as a new patient and look forward to working closely with you on achieving your health and wellness goals.
Please complete the enclosed enrollment forms:
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Patient Contact Information
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Health History Form
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HIPPA Release
Upon completion, please fax to LONGEVITY WELLNESS AND ANTI-AGING INSTITUTE at 312 980 1291 or bring it in completed at your first visit. We will process your forms and follow up with you shortly to coordinate your testing.
Thank you,
LONGEVITY WELLNESS AND ANTI-AGING INSTITUTE
LONGEVITY WELLNESS AND ANTI-AGING INSTITUTE
PATIENT CONTACT INFORMATION
Name: ___________________________________________________ DOB: _____________
Address: _____________________________________________________________________
City: ___________________________ State: ________________ Zip: _________________ÂÂÂÂ__
SS# ______________________________
Referral Source________________________________________________________________
Marital Status: Married [ ] Single [ ] Divorced [ ] Widowed [ ] Significant Other [ ]
Male [ ] Female [ ]
Number of Children [ ] Number of Grand Children [ ]
Occupation: ___________________________________________________________________
Email: __________________________________________________
Phone: Home # ___________________ Office # _________________ Cell # ______________
Fax: Home # ___________________ Office # _________________
[ ] I prefer to be contacted at: Home [ ] Office [ ] Cell [ ]
[ ] I prefer that our correspondence be by: Email [ ] Phone [ ] Fax [ ]
Note: All correspondence I strictly confidential. If you would like to have your medical records sent to your physician, please sign the release below for medical records and list:
Name of Physician: _____________________________________________________________
Address: ______________________________________________________________________
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LONGEVITY WELLNESS & ANTI-AGING INSTITUTE
HEALTH HISTORY FORM
NAME_____________________________________________________DOB:________________
REASON FOR YOUR VISIT
__________________________________________________________________________________
PAST MEDICAL HISTORY (Please Check All That Apply)
( ) High Blood Pressure
( ) Diabetes
( ) High Cholesterol
( ) Cancer
( ) Heart Disease
( ) Blood Disorder (Bleeding or Clotting)
( ) Thyroid Disease
( ) Arthritis
( ) Lung Disease
( ) Liver Disease (Hepatitis)
( ) Kidney Disease
( ) Gastro-intestinal Disease
( ) Mental or Psychological Issues
( ) AIDS or HIV Positive
( ) Other
PAST SURGICAL HISTORY (Please List)
_________________________________________________________________________________________
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FAMILY HISTORY (Please Check All That Apply)
( ) Diabetes
( ) Cancer
( ) Heart Disease
( ) High Blood Pressure
( ) Stroke
( ) High Cholesterol
( ) Obesity
( ) Mental or Psychological Problems
( ) Other
MEDICATIONS (Please List)
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VITAMINS & SUPPLEMENTS (Please List)
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ALLERGIES (Please List)
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SMOKING STATUS (How Much?)
( ) Cigarrettes ( ) Cigars ( ) Marijuana
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WEEKLY ALCOHOL INTAKE
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RECREATIONAL DRUGS (Please List)
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DATE OF LAST PAP SMEAR (Females)_____________________________________
DATE OF LAST MENSTRUAL PERIOD (FEMALES)________________________
DATE OF LAST MAMMOGRAM (Females)_________________________________
DATE OF LAST PSA TEST (Males)___________________________________________
DATE OF LAST SCREENING COLONOSCOPY_______________________________
SIGNATURE OF PATIENT____________________________________________________
HIPAA RELEASE
Patient understands and agrees to allow LONGEVITY WELLNESS AND ANTI-AGING INSTITUTE (LWAA) to use their patient history information for the purpose of treatment payment, healthcare operations and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning these records.
If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Healthy Information we encourage you to read the HIPAA NOTICE of PRIVACY PRACTICES, that is available to you at the front desk (or it can be emailed to you) before signing this consent
.
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Patient (Parent/Guardian) Signature Date
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Printed Name
