integrative longevity institute of virginia lambert titus ... · lambert titus k. parker, md 129 w....

INTEGRATIVE LONGEVITY INSTITUTE OF VIRGINIA

Lambert Titus K. Parker, MD

11/2015

Welcome to our practice! Please take the time to fill out our health assessment. We know that it is long and detailed but do believe that the more details we have, the better we can serve you. Please have this assessment completed prior to your appointment time so that you can maximize your time spent here in the office. If you only want to fill out the basics, that is ok, too! We can have your complete any additional information needed at a later date.

Patient Name: ___________________________________________________ Today’s Date:__________________________Date of Birth: _____/_____/_____ Address: _________________________________________________________ City: ___________________________State: ______________Zip: __________ Home Phone: (_____) ______________Cell Phone: (_____) ________________ Work Phone: (_____) _______________Fax: (_____) _____________________ Email Address:_____________________________________________________ Preferred Method of Contact:__________________________________________ Emergency Contact:_____________________________Relationship:__________ Phone Number: ____________________________________________________ Referred By:______________________________________________________ Is there a legal case pending, regarding the problem for which you are now seeking help? No_____ Yes_____ Do you wish to receive our Newsletter and Education Talk Flyers via email? No_____ Yes_____ ______________________________________________________________________ Patient Signature Date



11/2015

Primary Care Physician:________________________________ ________________________________ Telephone Number: (____)___________ Other Providers:______________________________________________ _________________________________________________ _________________________________________________ Current Issues: Primary Reason for Medical Evaluation: (Problem, Illness, Symptom, Experience, Goal) Check all

that apply, and rank them from 1 – 8 in order of importance (1= is most important, 8= the least)

( ) Physical Illness ( ) Weight Problem ( ) Mental/Emotional ( ) Work Issues ( ) Energy ( ) Finances ( ) Relationship(s) ( ) Sexual ( ) Spiritual ( ) Other (please specify) __________________________________________

Name your main concern: Be specific (Example: joint pain due to arthritis; stress due to work.

You can also review the Symptom Check List to help clarify your main concern.)

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ In your own words, and not in medical terminology, briefly describe how and when your main concern started, how it has progressed over time, and how it is now affecting your life. Date of Onset: _________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________



11/2015

Medical History: Please note any medical issues, diagnosis, accidents, injuries or trauma that you have had ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Surgical History: Note the year of surgery. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ FAMILY HISTORY

Father Mother Children Siblings Paternal Parents Maternal Parents

Alcoholism Alzheimers Asthma Bleeding Disorder Diabetes Epilepsy/Seizures Glaucoma Hair Loss Heart Disea High Blood Pressure Kidney Disease Mental Illness Migraines Obesity Stroke Alive age

Deceased age

CANCER

(Type)



11/2015

SOCIAL HISTORY: Occupation: ___________________Employer:_____________________ Currently: ( ) Single ( ) Married ( ) Divorced ( ) Separated ( ) Widowed If married, how long? _____________________ If divorced, how long? ___________________ Spouse’s Name: ____________________Spouse’s Occupation: ________________________ Children: Number, total: _______ Number, girl(s): ________Number, boy(s): ________ Ages of Children: ______________________________________________________________ Alcohol Consumption:___________ drinks per day week month year never What type of alcohol:_____________________________________________________ Do you feel you have a drinking problem? ( ) Yes ( ) No Tobacco History: Currently Smoke? ( ) Yes ( ) No # of packs per day?_________# of years________ Previous Smoker? ( ) Yes ( ) No # of packs per day?__________# of years_______ Year stopped smoking:__________ Illicit Drug History: Have you ever used any illicit drugs? If yes, please list type and amount and when the last time used was? (This information remains confidential)____________________________________ Educational history:____________________________________________________________ Religious Preference:___________________________________________________________

Current Height & Weight: _______________________________________________________ Do you have a history of a weight problem? ( ) Yes ( ) No Type:__________________________ Have you gained or lost 10% or more of your normal weight in a period of one year?

( ) Yes ( ) No Gained # of pounds _______ Lost # of pounds _______ Do you follow a special diet? ( ) Yes ( ) No Type:_________________ How many meals a day?_____________

Weight Height Age Waist size Dress or Suite Size

Current:

High School:

Current Exercise Regimen: Activities, Duration and Frequency:___________________ ______________________________________________________________________

Would you like information on a Personal Training Program?______________________



11/2015

Current Supplements

Supplements Manufacturer Form Dose Frequency How Long?

Example: Vitamin E GNC Cap 400iu 1 x day 1 year

Current Prescription Medication Sheet

Form: Liquid= liq Capsules= cap Tablets=tab Injections= inj

Medication Form Dose AM Noon Evening Bedtime How Long?

Example: Lotrel Cap 5/10 1 - - - 4 weeks

Allergies to Medication:___________________________________________________



11/2015

Symptom Check List (Check those you have had in the past and circle those

currently bothering you)Constitutional o Weight loss/gain o Fatigue o Exhaustion o Exhaustion after o exertion o Physical Pain o Libido, change o Frequent infections o Malaise o Fevers o Allergy o Chemical sensitivity

Skin

o Acne o Rash o Eczema o Dry skin o Itching o Rough skin o Easy bruising o Hives o Slow wound healing o Excessive perspiration o Sweaty palms and feet o Color change o Hair o Nails

Head

o Head acne o Migraine o Head injury o Hair loss

Eyes

o Vision: Glasses o Contacts

o Pain o Double vision o Glaucoma o Cataract o Eye itching o Eye soreness o Eye watering o Eye redness

Ears o Ringing in your

ears o Vertigo o Earaches o Ear infections o Discharge o Ears sore o Ears itching o Ear pressure

Nose & Sinuses o Frequent colds o Nasal Stuffiness o Nasal discharge o Nasal itching o Nose Congested o Constantly o Intermittently o Nose runny o Nose itching o Sneezing o Hay fever o Nose bleed o Post nasal drip Mouth & Throat o Bleeding gums o Sore tongue o Frequent sore

throats o Hoarseness o Throat swelling o Sort throat o Cough

Neck

o Swollen glands o Swollen neck o Goiter o Neck pain o Neck stiffness

Breasts

o Lumps o Pain or

discomfort o Nipple discharge o Self examination

Respiratory o Shortness of

breath o Asthma o Wheezing o Smothering feeling o Tight chest o Pleurisy o Chest pain o with breathing o with coughing o with exertion o Cough o Sputum production o White o Yellow o Green o Sinus infections o Bronchitis o Pneumonia o Tuberculosis o Last Chest X-Ray:

_________________

Cardiovascular System o Heart Problem o High Blood

Pressure o Rheumatic Fever o Heart murmur o Chest pain o Chest pain on

exertion o Palpitation o Irregular pulse o Rapid pulse o Slow pulse o Dyspnea (short of

breath) o Short of breath o Lying down o Leg pain on

exertion o Swelling of

feet/legs/hands o Cold hands and

feet o Leg cramps o Varicose veins o Thrombophlebitis

Gastrointestinal o Mouth ulcers, o canker sores o Mouth-tongue, raw o or sore o Heartburn o Excess acidity o Gastritis or acid o stomach o Gastric ulcers o Sugar cravings o Food cravings o Loss of appetite o Abdominal pain o Indigestion o Gas pains o Hypoglycemia, faint o feeling if meal is o missed o Nausea o Vomiting o Vomiting blood o Passing gas o Abdominal bloating o Constipation/Diarrhea o Black tarry stools o Rectal itch o Hemorrhoids o Jaundice o Liver problem o Gallbladder problem o Hepatitis

Urinary System

o Frequent urination o Burning on urination o Pain on urination o Hesitation to start o urination o Obstruction to urine o flow o Loss of urine with o coughing, straining o or activity o Urinary tract o infections o Bed-wetting



11/2015

Genitoreproductive MALE

o Hernia o Penis discharge o Sore on penis o Testicular pain o Testicular mass o Scrotal itching o Problem with erection o Problem with o ejaculation

FEMALE o Vaginal soreness or

burning o Vaginal itch o Vaginal discharge or

infections o Hair growth, face o Irregular menstrual

periods o Menstrual cramps o Development of o symptoms during the o time prior to o menstruation: o Headache o Fluid retention o Weight gain o Increased appetite

Musculoskeletal o Muscle stiffness, o swelling o Muscle soreness o Muscle cramps o Muscle jerks o Arthritis/joint o pain/gout o Back pain, neck

pain o Limited range of o motion of any

joint Hematological

o Anemia o Easy bruising or

bleeding o Blood transfusion o Reaction to blood

transfusion Endocrine

o Thyroid problem o Heat intolerance o Cold intolerance o Excessive

sweating o Diabetes o Excessive thirst o Excessive hunger o Frequent

urination

Neurological o Trouble falling

asleep o Trouble staying

asleep o Trouble waking up o Trouble staying

awake o Tired most of the

time o Weakness o Lack of Endurance o Depression o Loss of pleasure o Crying spells o Agitation o Excess worry o Phobic or fearful o Panic attacks o Anxiety o Suspicious o Irritability o Anger o Delusions o Hallucinations o Tremor o Seizures o Feeling shaky o Numbness o Tingling

o Hyperactive o Distractible o Balance problems o Dizzy or fainting o Blackouts o Poor concentration o Memory problem o Trouble thinking

Indecisive o Confusion o Learning disability o Speech problems o Taste, diminished/gone o Smell, diminished o Vision, blurry o Vision, double o Hearing loss o Ears ringing o Poor temperature o regulation o Headache, tension o Headache, migraine

For Women: Date of last PAP: ______________Results:_______________First day of last menstrual period: ________________ How old were you when your menstrual periods started?________________________________________________ Cycle: regular ______ irregular_______ Cycle consists of __________ days and ________ of bleeding. Bleeding: Mild _______ Moderate________ Heavy_________ Bleed or spot between Cycle: ( ) Yes ( ) No Do you have premenstrual symptoms? ( ) Yes ( ) No ( ) In past ( ) bloating ( ) irritability ( ) fatigue ( ) other How old were you when you had your first child? ____________ # of children_______ Ages____________________ No. of pregnancies__________Deliveries_______________ # of miscarriages ________ # of abortions __________ How many of your blood relatives (mother, sisters, or grandmothers only) have had breast cancer________________ _____________________________________________________________________________________________ Date of last Breast Exam: _______ ( ) was normal ( ) abnormal Have you had Breast Cancer: ( ) Yes ( ) No Hysterectomy (Uterus Removed)_______________Ovaries Removed _______________Age _________________ How many mammograms have you had? _________________When was your last mammogram?_______________ What was the result?____________________________________________________________________________ Age of Menopause Onset? ________________Do you experience any menopause symptoms? ( ) Yes ( ) No Which ones? __________________________________________________________________________________

Thank you!!

INTEGRATIVE LONGEVITY INSTITUTE OF VIRGINIA Lambert Titus K. Parker, MD

129 W. Virginia Beach Blvd, Suite 120 Norfolk, Virginia 23510

(757) 226-8880 Office www.integrativelongevity.org (757) 226-8883 Fax

INFORMED CONSENT STATEMENT

Authorization and Release of Medical Information: I authorize Dr. Lambert Titus Parker and Integrative Longevity Institute of Virginia to obtain, disclose, or verbally exchange with any of my previous physicians the following information:

Admission and discharge summaries Pertinent medical and psychiatric information relevant to my diagnosis and treatment Any labs or diagnostic previously obtained

Care Obtained from Other Facilities: It is my obligation to advise Dr. Lambert Titus Parker and Integrative Longevity Institute of Virginia of any other physicians whom I consult concurrent to obtaining medical care here. It is my responsibility to provide Integrative Longevity Institute of Virginia with a complete and current list of all medications that are prescribed by other physicians and administered concurrent to care obtained from Integrative Longevity Institute of Virginia.

CONSENT TO TREATMENTI acknowledge that entering into any doctor-patient relationship, including this one, may lead to medical risks.

Statement Regarding Treatment Outcome: No medical practitioner, using conventional, alternative, or integrative approaches, can guarantee results to a patient. By signing this Informed Consent statement, I acknowledge that there are no guarantees of results with these treatments.

Resolution of Disputes Regarding Care: It is the intention of the parties to resolve all disputes as cordially and efficiently as possible. In an effort to effect these goals, except as otherwise provided by applicable law, the parties agree to mediate all disputes relating to the patient’s medical treatment, which mediation should take place in Norfolk, Virginia. Both parties agree to participate and to devote their best efforts to resolve the dispute relating to treatment through mediation. Such mediation shall not be binding.

In the event that the treatment dispute is not resolved through mediation, the parties agree to participate in arbitration in Norfolk, Virginia. The arbitration shall be conducted in accordance with rules substantially similar to those of the American Arbitration Association (the "Association") then in effect. The arbitration does not have to be conducted through the auspices of the Association. The arbitrator shall be mutually appointed by the patient and Dr. Lambert Titus Parker. The parties shall have the right to withdraw from the arbitration and to decline to submit any matter to arbitration within sixty days after the termination of the patient’s receipt of health care from Dr. Parker. Unless otherwise terminated as outlined above, any award entered by the arbitrator shall become final, binding and not appealable and judgment may be entered thereon by




either party in accordance with applicable law in any court of competent jurisdiction. This arbitration provision shall be specifically enforceable. The arbitrator shall have no authority to modify any provision of this Agreement or to award a remedy for a dispute involving this Agreement other than a benefit specifically provided under or by virtue of the Agreement. Each party shall be responsible for its own expenses relating to the conduct of the arbitration (including reasonable attorneys' fees and expenses) and shall share the fees of the Arbitration equally. In the event a party opts to terminate arbitration proceedings under the conditions set forth above, that party will bear the reasonable expenses of both parties.

Integrative Longevity Institute of Virginia and Dr. Parker reserve the right to pursue all matters unrelated to the patient’s treatment (e.g., collection matters) in accordance with their rights under the law. The above provision should not be construed to hinder such rights in any way.

No FDA Approval: I specifically understand that the United States Food & Drug Administration (FDA) has not approved a variety of therapies that are utilized, including, but not limited to, certain nutritional therapies and hormone therapies [including but not limited to, natural estrogen, natural dehydroepiandrosterone (DHEA)]. In addition, I understand that many conventional therapies may be used in an unapproved manner, differing from their FDA-approved usage. For example, the FDA has granted approval of Cranial Electrical Stimulation (CES) for anxiety, depression, and insomnia, but it may also be used for a variety of other medical conditions.

Natural-based Therapies: Integrative Longevity Institute of Virginia has discussed with me all known risks and side effects associated with natural-based treatment techniques which I have chosen to undergo, or am presently undergoing, after giving my informed consent.

Integrative Longevity Institute of Virginia’s Approach to Medical Care: I am aware that in some instances, this medical facility may prescribe medications and therapies for applications other than those, which have obtained FDA approval. I understand that these applications are based on empirical clinical experience and validated by scientific data. I am aware that the Integrative Longevity Institute of Virginia’s approach differs from conventional medical care as dispensed by a university-type hospital center.

Statement of Fees: Consultation fees include, but are not limited to: New Patient Visit……………………………….……$250.00 initial Subsequent Office Visits ……………………………$125.00/15 minutes

Diagnostic evaluations (including blood work), treatments (including supplements and Medications) are not included in these fees, and are subject to change.

As a patient, you acknowledge that payment in full is required at the time of your visit.




Financial Arrangement and Medical Insurance Information: Our billing relationship is with you, not your health insurance carrier. Unfortunately we cannot guarantee that your insurance company will reimburse you. All services unless stated otherwise are contracted through the institute.

As a patient, you acknowledge the following: Your insurance coverage is a contract between you, your insurance carrier, and your employer. We do NOT bill or forward medical information to any insurance carriers or third party payers.Not all services are covered benefits in all insurance contracts. Some insurance companies arbitrarily select certain services that they will not cover. You understand that you are responsible for prompt payment in-full.

Dr. Lambert Parker and Integrative Longevity Institute of Virginia do not accept Medicare or Medicaid.

Laboratory Fees: Blood drawn at this office is sent to an outside laboratory for analysis. The majority of our labs are contracted through us and part of the packaged care.

HIV Testing: By signing this Informed Consent Statement, I am consenting to HIV antibody testing and counseling in the event the physician requests it. This office will provide full explanation of the test(s) and possible ramifications, including, but not limited to:

The objective of the test is to determine the presence or absence of antibody to Human Immunodeficiency Virus (HIV).

The test for HIV Antibody is voluntary. This test is not a diagnostic for Acquired Immune Deficiency Syndrome (AIDS). Though most

patients with AIDS or the AIDS - related complex (ARC) have the HIV antibody, the reverse is not necessarily true. Some people with HIV antibody may not develop AIDS.

Repeatedly reactive HIV ELISA screening tests may be evidence of possible infection and may imply risk to developing AIDS or ARC. In addition, there is a low incidence of biological false positive results. Therefore, all reactive ELISA Tests will be confirmed by Western Blot.

Policy for Default in making Payments:

A $50.00 charge will be posted to any account for each a returned check.. This account will be charge 1.5% interest per month for balances not paid within ___ days from the date of any invoice. If the account becomes past due and is given to an attorney for collection the patient shall be responsible for all costs and attorney’s fees incurred in the collection of past due




accounts. Patient further understands and agrees that any suit arising from the doctor-patient relationship shall only be brought in a court of competent jurisdiction in the City of Norfolk, Virginia. Please discuss any questions or concerns regarding the cost of services with our Practice Manager.

By signing below, I hereby agree to the declarations contained in this Informed Consent Statement.

Name (print): ________________________________________________________

Signature: ___________________________________________________________

Date: ____________________ Social Security Number: __ __ __ - __ __ - __ __ __

Witness: ____________________________________________________________

Yearly Update Information (for established patients):

Address:_______________________________________________________________

City:_______________________________State:________________Zip:___________

Home Phone:________________________ Cell Phone:_________________________

Email:_________________________________________________________________


A 501(c)3 Non-Profit Medical Research Institute

129 W. Virginia Beach Blvd, Suite 120Norfolk, Virginia 23510

(757) 226 8880 Office www.integrativelongevity.org (757) 226 8883 Fax

INFORMED CONSENT STATEMENT

Authorization and Release of Medical Information:

I authorize Dr. Lambert Titus Parker and Integrative Longevity Institute of Virginia to verbally exchange with my significant other.

Name:

Relationship:

The following information: Summaries of findings Relevant diagnosis and treatment Relevant lab values

� NOT Genetic information.

By signing below, I hereby agree to the Consent Statement.

Name (print):

Signature:

Date: Witness: ________________________________


A 501(c)3 Non-Profit Medical Research Institute

129 W. Virginia Beach Blvd, Suite 120Norfolk, Virginia 23510

(757) 226 8880 Office www.integrativelongevity.org (757) 226 8883 Fax

RECORD RELEASE

Date:

Patients Name:

Date of Birth:

Social Security:

Patient’s Address:

I hereby give permission to have my relevant medical records released to Integrative Longevity Institute of Virginia. Please forward to the address listed below.

Copy of all medical records.

Copy of all Lab results.

Other:

Signature:

Name: Date:

Integrative Longevity Institute of VirginiaInternal Medicine / Integrative Longevity Medicine

A 501(c)3 Non-Profit Medical Research Institute LAMBERT TITUS K. PARKER, MD

129 W. Virginia Beach Blvd, Suite 120, Norfolk, Virginia 23510 Office: (757) 226-8880 www.integrativelongevity.org Fax: (757) 226-8883

1

For ALL Medicare Patients:

This serves as your notice that Lambert Titus Parker, MD has chosen to Opt Out of being part ofthe Medicare program. Patient beneficiary or his/her legal representative agrees, understandsand expressly acknowledges the following:

Beneficiary or his/her legal representative accepts full responsibility for payment of thephysician’s charge for all services furnished by the physician.Beneficiary or his/her legal representative understands that Medicare limits do notapply to what the physician may charge for items or services furnished by the physician.Beneficiary or his/her legal representative agrees not to submit a claim to Medicare orto ask the physician to submit a claim to Medicare.Beneficiary or his/her legal representative understands that Medicare payment will notbe made for any items or services furnished by the physician that would have otherwisebeen covered by Medicare if there was no private contract and a proper Medicare claimhad been submitted.Beneficiary or his/her legal representative enters into this contract with the knowledgethat he/she has the right to obtain Medicare covered items and services from physiciansand practitioners who have not opted out of Medicare, and the beneficiary is notcompelled to enter into private contracts that apply to other Medicare covered servicesfurnished by other physicians or practitioners who have not opted out.Beneficiary or his/her legal representative understands that Medi Gap plans do not, andthat other supplemental plans may elect not to, make payments for items and servicesnot paid for by Medicare.Beneficiary or his/her legal representative acknowledges that the beneficiary is notcurrently in an emergency or urgent health care situation.Beneficiary or his/her legal representative acknowledges that a copy of this contract hasbeen made available to him.

______________________________________________________________________________Patient Signature Date

______________________________________________________________________________Lambert Parker, MD or Staff Representative Date

integrative longevity institute of virginia lambert titus ... · lambert titus k. parker, md 129 w....

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