Medical Questionnaire Form Medical Questionnaire Step 1 of 7 14% HEALTH HISTORYPatient Name: First Last Date of Birth: MM DD YYYY Age:Sex: Male Femaile Address: Street Address City State / Province / Region ZIP / Postal Code Phone:Additional Phone:Email: Primary Physician:Reason for seeking treatment?Are you a Professional Athlete Subject to PED screening / testing? Yes No BASIC EXAMINATION:Height:Weight:BP:Pulse:PRODUCT USAGE:TOBACCO How often:ALCOHOL How often: CAFFEINE How often:ALLERGIES: (Check all that apply) Aspirin Codeine Dye Allergies Food Morphine Nitrate Penicillin Pet Seasonal Sulfa Drug Other: NO KNOWN ALLERGIES OVER THE COUNTER MEDICATIONS: (Check all that apply) Acetaminophen Acid Blockers Antacid Antidiarrheal Antihistamines Aspirin Cough Suppressant Decongestant Diet Aids Ibuprofen Ketoprofen Laxatives Naproxen Pain Reliever Sleep Aids Other:PAST / PRESENT MEDICAL CONDITIONS: (Check all that apply) Arthritis Blood Clotting Issue Cancer Depression Diabetes Epilepsy Heart Disease High Blood Pressure High Cholestrol Hormone Related Lung Disease Migranes Suicidal Thoughts or tendencies Thyroid Ulcers List any other medical conditions: Current Medications / Vitamins / Supplements. Please list strength, date started, and dosage per day.FAMILY HISTORY: (Father, Mother, Siblings only)Arthritis Yes No Cancer Yes No Diabetes Yes No Heart Disease Yes No High Blood Pressure Yes No Skin Disorders Yes No If OTHER, Please list disease / condition and relationship: WOMEN ONLYAre you currently pregnant? If I become pregnant while on this program, I will immediately discontinue any of the medications on this program. Yes No Last Menstrual Cycle: Are you currently breast feeding? Yes No Have you ever had what you consider an abnormal period cycle? Yes No If YES, Please Explain:Any history of Breast or Female Organ Cancer? Yes No I HERBY DECLARE that, to the best of my knowledge and belief, the information given in these answers to My HCG Store is correctly recorded, complete and true and I agree that My HCG Store, believing them to be true, shall rely and act upon them accordingly. Patient Signature: Welght-Loss Consumer Bill of Rtghts 5O1.O575 [1) The Weight-Loss Consumer Bill of Rights shall consist of the following provisions: (A) Warning: rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 1/2 to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight loss program. (B) Consult your personal physician before starting any weight-loss program. (C) Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long term weight loss. (D) Qualifications of this provider are available upon request. [E) You have a right to: (1) Ask questions about the potential health risks of this program and its nutritional content psychological support and educational components. (2) Receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations, and laboratory tests. (3) Know the actual or estimated duration of the program (4) Know the name, address, and qualifications of the physician, dietician or nutritionist who has reviewed and approved the weight- loss program according to 468.505(1Xi). Florida Statutes. My HCG Store is a licensed non-diagnostic preventative health care provider. Our doctors and medical staff directly prescribe all required tests and review and confirm all test results, We may also perform physical exams, consult with primary physicians, and validate and verify submitted medical information. Patients who are found to have signs and symptoms of a legitimate medical and/or health condition are referred to a medical specialist in that field for diagnosis and treatment in a specialized and monitored program. My HCG Store reserves the right to recommend and use internal and / or external medical specialists for any a patient and all patient information will be protected under all HIPPA laws and regulations. My HCG Store is not an internet pharmacy and does not dispense, ship, or distribute medications from our facilities or web sites. Any and all medication prescribed by our doctors and/or associated medical associates for medical treatment will be dispensed from a US FDA approved pharmacy. All patients are required to fulfill and follow all of the medical instructions and procedures prescribed by doctors and contact us immediately if they have any problems, questions, or concerns. Patients whom are found to have submitted fraudulent information will be terminated from any health program offered by My HCG Store or any of its affiliates. Any medication prescribed is only for the use of the patient and is not to be transferred, distributed, modified, or used by any other party. "Off Label" Use of HCG I understand that this therapy includes "off-label" use of the FDA approved medication HCG Human Chorionic Gonadotropin. I understand that this medication is FDA approved for other medical treatment modalities and has not been approved for the purpose of weight loss. ("Off-label" use means the use of FDA approved drugs for purposes other than those for which the FDA has approved them.) "Off-label" prescribing is a legal and common practice by physicians in tlte United States. Statement from the FDA I have been notified that since 1975, the FDA has required labeling and advertising of HCG to state: "HCG has not been demonstrated to be an effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or "normal" distribution of fat or that it decreases the hunger and discomfort associated with calorie-restricted diets." I have read and understand the above acknowledgments:Patient Signature: TERMS AND AUTHORIZATION In consideration of instructs from My HCG Store, Inc. ("My HCG Store") providing the undersigned patient ("Patient") with medical management, administrative and referral services, Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement (' agreement"). With this agreement, Patient submits with this agreement an accurately completed Medical History Form ("MHF"). Patient agrees to respond to truthfully, accurately and completely in completing the MHF or any agent sent by My HCG Store to complete the form and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to My HCG Store or the physicians referred by My HCG Store could result in inappropriate treatment. Patient authorizes My HCG Store to obtain on my behalf medical laboratories, diagnostic testing. physicians and dispensing pharmacies. In addition, Patient authorizes and instructs My HCG Store and physicians referred by My HCG Store("Physicians") and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the MHF, laboratory diagnostic tests, and other information submitted to My HCG Store under this agreement. Patient agrees to present photo identification upon any blood testing pursuant to a My HCG Store or Physician test requisition. Patient acknowledges that therapies and laboratory and diagnostic testing services supplied or obtained by My HCG Store and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance. Patient acknowledges that My HCG Store's employees and agents are not licensed physicians and that Physicians obtained on my behalf by My HCG Store are independent contractors, which will be compensated by Patient with funds provided to My HCG Store. Patient acknowledges that My HCG Store does not practice medicine and that My HCG Store is a medical management, administrative, and referral service and does not direct, control, or influence the treatment decisions made by Physician. I further understand and agree that My HCG Store and Physicians are rendering the medical care, services and treatment and that My HCG Store is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by any pharmacy in my country of residence. Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by the Physician, to immediately cease any medical treatment prescribed by the Physician in the event of any adverse reaction or side effect arising from prescribed treatment, and to immediately provide My HCG Store and Physician with written notice via fax to (888) 831-4818 of any such adverse reaction or side effect. I further acknowledge and agree that My HCG Store is not liable for any negligent act or omission of the Physician. Patient acknowledges that diagnosis and treatment may involve risk of injury, and that My HCG Store and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing. analysis of test results, examination of medical history or hormone treatment. Patient acknowledges that the hormone blood level objective sought as a result of the Patient's hormone replacement therapy, as prescribed by Physician, may be at the highest level of a standard reference range for Patient's age and sex, or, in some cases, above such range, to the level of a younger person, and that such range Is experimental and may not render any benefits, but may result in unknown, adverse results. Patient is aware of the nature, risk, and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone replacement treatment. Patient acknowledges that recombination human growth hormone replacement therapy involves the use of a medical drug approved for one purpose for a new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone replacement therapy for the purpose of authorizing Physician to administer such treatment to relieve body ailments and attempt to enhance Patient's physical condition and health. Patient further acknowledges that the methods of medical treatment offered by My HCG Store and Physician are not accompanied by any claims, guarantees, promises or warranties. It is fully agreed and understood by the patient that products purchased from My HCG Store require a medical prescription and as such are NOT returnable or refundable under any circumstances under both Federal and/or State laws. It is unlawful for a pharmacy to accept the return of prescription medications once they have left the control of the pharmacy. Patient is freely seeking medical consultation via the Internet or direct contact and acknowledges and consents to Physician reviewing Patient's medical history without having the opportunity to conduct an in-person physical examination. Patient solicits My HCG Store for a specific prescription medication to treat an already-identified medical or cosmetic condition. Patient acknowledges that Physician may not be licensed to practice medicine in the Patient's state or country of residence. Further, Patient agrees that Physician's consultations, diagnoses, and treatments will be deemed to have occurred in Florida, where Physician is licensed to practice medicine. Patient represents that he or she is under the care of a primary care physician and that physicians will not rely or substitute the advice of physician should it conflict with the advice given to me by patient's primary care physician. Before taking any medication prescribed by physician, patient agrees to have a comprehensive physical examination by his or her primary care physician. Patient agrees to notify his or her primary care physician and advise such physician that the patient is undergoing hormone replacement therapy. Patient acknowledges that under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. PHYSICIAN HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law. Patient acknowledges and agrees that My HCG Store is not responsible for the negligent or intentional acts or omissions of any health care provider or supplier that Patient is referred or for any action or inaction taken by Patient, that the total liability of My HCG Store, its officers, directors, employees, agents, and stockholders is limited to the purchase price of any products through My HCG Store Physicians or Pharmacies, and the My HCG Store and Physicians will not be liable for any direct, indirect, special, incidental, consequential, or punitive damages. During Patients relationship with My HCG Store and Physician, My HCG Store and Physician will convey to Patient a range of proprietary business information, including. confidential disclosures and trade secrets business practices and My HCG Store’s customers and suppliers ("Confidentiallnformation'1. No matter how received by the Patient during the parties' relationship, Patient agrees that Confidential Information is confidential, proprietary and uniquely valuable to My HCG Store and gravely affects the conduct of business of My HCG Store and My HCG Store’s goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner; either directly or indirectly, any Confidential Information or take any action that may result in disclosure of Confidential Information to any third party person, firm, or business. Patient agrees that if the terms of this paragraph are breached, My HCG Store shall be conclusively deemed to be irreparably injured and shall be entitled to an injunction restraining Patient from disclosing any Confidential Information and to liquidated damages. Patient agrees that the amount of My HCG Store's actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such liquidated damages are not a penalty. Based on the above-understanding. Patient agrees to release My HCG Store, its officers, directors, employees, agents and shareholders, and Physician from any and all liability associated with or arising from the Physician's consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physician's consultation. This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Hillsborough County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees. This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void, and of no effect If any provision of this Agreement or the application thereof to any person or circumstances is invalid or unenforceable in any jurisdiction, the remainder hereof, and all application of such provision to such person or circumstances in any other jurisdiction, shall not be effected thereby, and to this end the provisions of this Agreement shall be severable. Patient covenants and agrees to indemnify, defend, protect, and hold harmless, and Physician and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates ("Indemnified Parties") from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigation, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paired by the Indemnified Parties in connection with, resulting from, or arising out of, directly or indirectly, My HCG Store and/or Physician's rendering medical care services, advice and/or treatment, Patient's failure to disclose all relevant Information regarding Patient's medical and physical condition, acts or omissions of My HCG Store or Physician, harm or Injury resulting from medical care or pharmaceuticals provided directly or indirectly by My HCG Store or Physician. Patient is aware of potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties there from. Patient Signature: This iframe contains the logic required to handle Ajax powered Gravity Forms.