- Step 1 of 29

Bio-identical Hormone Replacement Therapy Program Disclaimers

As discussed, the annual fee for the BHRT program is $8,800.

1) All consultations are subject to a $1000. non-refundable booking fee.

2) If you proceed with the program, the remainder of the annual fee is due at the first visit.

3) The consultation is NOT covered by OHIP or by private insurance.

Patient Name *

First

Last

Date (copy) *

I give my consent to the administration of the above named BHRT, TRT, thyroid treatment, melatonin, and lab tests as needed. *

Bio-identical Hormone Replacement Therapy Program Intake Form (M)

Personal Demographics

Full Name *

First

Last

Date of Birth *

OHIP Number *

Expiration Date *

Current Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Phone Number

Cell Phone Number *

Other Contact Number

Email *

Emergency Contact *

First

Last

Marital Status

Phone Number *

Employer

Position

Primary Care Provider

Primary Care Provider Name *

First

Last

Phone Number *

Fax Number

Primary Care Provider Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Past Medical History

Please list any medical problems or illnesses you have had or continue to have. Include any hospitalizations and accidents with approximate dates.

Medical Diagnosis/illness/accident

Past Surgical History

Specialists/Other Health Care Providers

Medications

Hormone Therapy History

Do you have a preferred route in which you would like to take your prescribed hormone therapy?

By Mouth (under tongue, capsules/tablets)
Through the skin in creams or patches
Intramuscular injections or subcutaneous
No preference
Other

If Indicated Other Please Explain

Please note that certain routes may not be available nor recommended - your practitioner will counsel you on best routes based on your medical history.

Allergies

Family Health History

Family History

Cancer History

Do you have a history of any of the following cancers or were you ever investigated for abnormalities in any of the following systems/anatomical sites?

Thyroid
Colon
Rectum
Pancreas
Liver
Lung
Other

If indiciated other, please share additional details.

Social History

Please remember that this information is strictly confidential and will be used only to address your symptoms and/or complaints.

Do you smoke cigarettes now or have you in the past?

How many total years have you smoked?

If yes, how many packs per day?

Do you drink alcohol?

If yes, how many drinks and what type of alcohol (beer, wine, spirits, etc.) do you have in an average week?

1-2
3-7
8-14
15+ per week

Do you now or have you in the past used any recreational drugs (marijuana, cocaine, opiates, amphetamines, narcotics, LSD [acid], etc.)?

If yes, what substance(s) and how often?

Do you drink coffee/caffeinated beverages?

If yes, how many cups (8oz/250ml) do you drink on average/day?

1-2 cups
3-4 cups
4-5 cups
A whole pot or more to stay awake

Exercise/Activity Level

Do you participate in regular physical activity or exercise?

On average, how many days per week do you exercise?

What activities do you engage in?

How many minutes per day?

Do you have activities or hobbies you wish to engage in, but have not as of yet?

Stress Experiences

In the past 12 months, how often have you felt excessive stress in your life?

Never
Occasionally
Often
Almost always

Have you had any recent life stressors in the past 3 years?

Please list of describe any recent life stressors in the past 1-3 years (divorce/marriage, change of address, difficult boss, new job, etc):

Do you have any history of traumatic events, violence, conflict, or living in an abusive environment?

If yes, when did these occur? (Please check all that apply)

Early childhood (age 0-12 years)
Teenage/young adult (age 13-24 years)
Adult (age 25-44 years)
Midlife (age 45-64 years)
Adult (age 25-44 years) □ Midlife (age 45-64 years) O

Nutrition Practices

In general, you say your nutritional intake is:

Excellent
Very Good
Good
Fair
Poor

How many vegetable servings do you consume daily on avg? (This does not include fruit servings)

Hardly Ever
1-2 Servings
3-4 Servings
4-8 Servings
8+ Servings

How many servings of water do you drink daily on average? (A serving is 1 cup/250ml8oz.)

Hardly Ever
1-2 Servings
3-4 Servings
4-8 Servings
8+ Servings

Sleep Practices

Please answer if sleep is an issue you would like addressed

I would rate my sleep quality as:

Excellent
Very Good
Good
Fair
Poor

How many hours of sleep on average do you get each night?

Less than 4 hours
4-6 Hours
6-8 Hours
8+ Hours

On average, how long does it take to fall asleep?

I fall asleep right away
15-30 Mins
lie awake for a long time (1 hour+)

Do you experience night time awakenings?

If yes, how many times on average do you wake up at night (Including to use the washroom)?

Sleep soundly at night
Toss & Turn
Im up 1-2 times
I'm up 2-3 times
I'm up 3+ times

In the morning when you wake up, you feel....

Invigorated and ready to go
Most times, feel refreshed
Frustrated that your sleep is cut short, but able to get up & get going
Like you haven't slept at all

Do you experience low energy/fatigue during the day?

If yes, please describe when this typically occurs, what are your symptoms, and what you normally do to relieve your symptoms:

My biggest problem with sleep is...(please check the MOST bothersome symptom)

Falling asleep
Frequent waking up during the night
Feeling refreshed in the morning

Overall Health Assesment

General Health History

In general, I would say that my overall health is:

Excellent
Very Good
Good
Fair
Poor

Do you have fever and chills?

Yes
No
Not Sure

Do you notice swollen lymph nodes?

Yes
No
Not Sure

Have you ever tested positive with HIV?

Yes
No
Not Sure

Do you have morning joint pain and stiffness lasting more than one hour?

Yes
No
Not Sure

Have you had unexplained weight loss?

Yes
No
Not Sure

Do you have night sweats?

Yes
No
Not Sure

Have you ever been diagnosed with cancer?

Yes
No
Not Sure

Have you ever had a sexually transmitted disease?

Yes
No
Not Sure

Do you suspect that you may have any inflammatory/autoimmune conditions? (eg. Lymes disease, Lupus, celiacs, etc)

Yes
No
Not Sure

Have you ever been diagnosed with any inflammatory/autoimmune conditions?

Yes
No
Not Sure

If yes, which one(s)?

Overall Health Assesment

General Health History Continued

Do you have a persistent cough?

Yes
No
Not sure

Do you have excessive daytime sleepiness?

Yes
No
Not Sure

Have you ever been diagnosed with asthma, COPD, or emphysema?

Yes
No
Not Sure

Do you have heart palpitations or often feel your heartbeat skipping?

Yes
No
Not Sure

Do you have unexplained swelling in your feet/ankles or in your arms?

Yes
No
Not Sure

Have you experienced any vascular disease or artery blockages/aneurysms?

Yes
No
Not Sure

Have you been diagnosed with any heart condition?

Yes
No
Not Sure

Have you ever been diagnosed with a blood clot or a bleeding/platelet disorder?

Yes
No
Not Sure

Do you have recurrent sinus infection?

Yes
No
Not Sure

Do you snore?

Yes
No
Not Sure

Do you have chest pain?

Yes
No
Not Sure

Do you have shortness of breath when walking/doing activities?

Yes
No
Not Sure

Do you experience pain or swelling in your calves?

Yes
No
Not Sure

Have you experienced aortic stenosis, heart valve issues, or heart murmurs?

Yes
No
Not Sure

Have you ever needed a stress test/cardiac test?

Yes
No
Not Sure

Have you ever had an issue with your cholesterol levels?

Yes
No
Not Sure

Overall Health Assesment

General Health History Continued

Do you have problems swallowing food? Choking symptoms?

Yes
No
Not Sure
Fair
Poor

Do you have diarrhea?

Yes
No
Not Sure

Have you ever had blood in your stool?

Yes
No
Not Sure

Have you ever been diagnosed with hepatitis or liver disease?

Yes
No
Not Sure

Do you have greater than normal urge to eat?

Yes
No
Not Sure

Are you excessively thirsty?

Yes
No
Not Sure

Do you have acne?

Yes
No
Not Sure

Do you have nausea or vomiting?

Yes
No
Not Sure

Do you have constipation?

Yes
No
Not Sure

Do you have abdominal discomfort with bloating and gas?

Yes
No
Not Sure

Do you urinate frequently or in larger amounts than usual?

Yes
No
Not Sure

Do you have elevated blood sugar? Diabetes?

Yes
No
Not Sure

Do you have facial hair?

Yes
No
Not Sure

Have you ever been diagnosed with a thyroid problem or told you have a borderline thyroid disorder?

Yes
No
Not Sure

Overall Health Assesment

General Health History Continued

Do you sometimes have muscle weakness or difficulty walking?

Yes
No
Not Sure
Fair
Poor

Have you ever fainted?

Yes
No
Not Sure

Have you ever been diagnosed with a stroke?

Yes
No
Not Sure

Do you have concerns of numbness or tingling in your hands/feet?

Yes
No
Not Sure

Do you have urgency when you urinate?

Yes
No
Not Sure

Do you leak urine when laughing or coughing?

Yes
No
Not Sure

Have you ever had a seizure?

Yes
No
Not Sure

Have you experienced double vision or blind spots?

Yes
No
Not Sure

Have you ever been diagnosed with any neuromuscular condition? Eg. Multiple Sclerosis, Parkinson's, tremors.

Yes
No
Not Sure

Do you have burning when you urinate?

Yes
No
Not Sure

Do you urinate more frequently than others or than before?

Yes
No
Not Sure

Have you ever had any kidney problems? Eg. cysts or stones

Yes
No
Not Sure

Have you ever broken/fractured a bone?

Yes
No
Not Sure

If yes, please provide the date and location of fracture(s)

Do you walk with a cane or mobility aid?

Yes
No
Not Sure

Have you used progestins for a duration greater than 1 year? Eg. Depo-provera

Yes
No
Not Sure

Have you been diagnosed with osteoporosis or osteopenia?

Yes
No
Not Sure

Have you ever been in a serious motor vehicle accident?

Yes
No
Not Sure

MALE Health History

Female Patients please skip to next section*

Has a healthcare provider ever diagnosed you with any of the following medical conditions? (Please check yes or no)

Benign prostatic hypertrophy

Osteoporosis or osteopenia

Erectile Dysfunction

Prostate cancer

Thyroid disorder

High blood pressure

Testicular cancer

Diabetes

Liver disease

Fibromyalgia

Epilepsy/Seizure disorder

Gastrointestinal Absorption Disorder (GERD/heartburn)

Any type of cancer or blood disorder. If yes, what type?

MALE Health History

Female Patients please skip to next section*

MALE Systems Assessment

Please review each category and mark which symptoms have been bothersome on a scale of 1 through 4

1-no symptoms 2-minimal 3-moderate 4-severe

Female Patients please skip to next section*

Extreme fatigue/tired or feeling exhausted

Headaches and/or migraines

Hot flashes/night sweats

Acne/oily skin

Urinary Frequency

Depression

Rapid mood changes/mood swings

Difficulty having/maintaining erections

Lack of energy/endurance

Lack of sex drive/libido/sexual desire

Difficulty falling and staying asleep

Bloating/water retention

Increased irritability and/or anger

Loss of body hair

Memory problems/forgetfulness

Increased anxiety

How strong are your morning erections?

Very hard and erect
Somewhat hard and erect
Not that hard
I hardly have morning erections
I do not have morning erections

FEMALE Health History

Male Patients please complete previous sections*

Gynecological History

Date of last PAP smear?

Date of last mammogram?

Date of last pelvic/abdominal ultrasound?

Results of mammogram

Results of ultrasound:

Have you ever had an abnormal PAP smear?

Have you ever had an abnormal mammogram?

If yes, what was the abnormality and what follow-up did you have?

Have you ever had a breast biopsy?

Have you ever had a cervical biopsy?

Have you noticed breast skin or nipple changes, or lumps in your breast?

Have you ever needed to do a breast ultrasound?

Are you using a birth control method?

If yes, what was the reason for the test?

If yes, what kind?

Are you still having menstrual periods?

If yes, when was the first day of your last period?

FEMALE Health History

Male Patients please complete previous sections*

Menstrual Period History

Age periods began

If you are now deemed menopausal, have you ever had any episodes of vaginal bleeding or spotting?

If your periods stopped less than one year ago, how many months ago was your last period?

If you are no longer having periods, at what age did your periods stop?

Did you periods stop because you had a hysterectomy?

If yes, what was the reason for the surgery?

Were the ovaries removed at the same time?

Yes
No
Not Sure

Please describe any problems you have with your periods, or have had (if you are now menopausal):

FEMALE Health History

Male Patients please complete previous sections*

FEMALE Symptoms Assessment

Please review each category and mark which symptoms have been bothersome on a scale of 1 through 4

1-no symptoms 2-minimal 3-moderate 4-severe

Male Patients please skip to next section*

Fatigue/tired and/or always exhausted

Food cravings - carbs/salty/sweet

Depression, feeling sad, low moods, tearful/crying

Irritability or increased anger/hostility to others

Lack of sex drive/libido/sexual desire

Pain with sex

Bloating/water retention or swelling (edema)

Forgetfulness/memory problems

Hair on face/chin - excessive hair on body

Thinning hair or hair loss

Loss of skin tone and/or increased wrinkles

Muscle weakness and/or loss of strength

Coffee/energy drink withdrawals

Lack of energy or endurance

Moodiness, rapid mood swings/mood changes

Increased anxiety or increased worrying

Vaginal dryness/irritation

Breast tenderness, sore/swollen breasts, breast changes/lumps, or fibrocystic breast disease

Headaches and/or migraines

Brain Fog/Difficulty focusing/Trouble thinking

Acne or pimple skin problems

Weight gain or difficulty losing weight

Increased skin injuries/thinner skin

FEMALE Health History

Male Patients please complete previous sections*

FEMALE Symptoms Assessment

Please review each category and mark which symptoms have been bothersome on a scale of 1 through 4

1-no symptoms 2-minimal 3-moderate 4-severe

Male Patients please skip to next section*

Weight loss

Cold intolerance/wearing more clothing than others

Dry Skin

Diarrhea/Loose Stools

Warm or flushed skin

Hand tremors/shakiness

Decreased motivation

Difficulty falling or staying asleep, insomnia

Heavy and/or irregular periods

Premenstrual disorder (symptoms days before menses)

Hot flashes/night sweats/nuclear meltdowns

All over body aches and pain, chronic pain syndromes

Brittle nails, cracked dry nails, nail changes

Heat intolerance - finding it's always too hot

Constipation

Difficulty handling stress, freaking out at times

Nervousness, heart palpitations, pounding/irregular heartbeats

Excessive sweating

Decreased ability to be arousedhave orgasms or decreased sexual pleasure

Snoring when asleep, sleep apnea

Abdominal cramps

Breast less full and/or sagging

Low back pain or joint pain

Have these symptoms occurred roughly at around the same time each month (cyclically)? Or have these symptoms occurred more randomly throughout the month?

Bio-identical Hormone Replacement Therapy Program Treatment Consent Form

The form is to specify my consent for treatment with a combination of integrative treatments, custom compounded prescriptions, bioidentical hormone replacement, and off-label medications.

1. TREATMENT - I understand that the methods of treatment provided by Dr. Kristy Bailey include, but are not limited to, bioidentical hormone restoration, BHRT, TRT, melatonin, HGH, and thyroid optimization. I understand that some of the custom compounded prescriptions, and off-label medications (all of which are at an extra cost) are part of my treatment plan and may have occasional side effects. I will immediately notify the clinic/prescriber by telephone or in person of any side effects associated with my use of this treatment, or medication. *

2. BENEFITS OF TREATMENT - I consent that Dr. Kristy Bailey has discussed with me the potential benefits and associated risks of taking or not taking BHRT, TRT, thyroid hormones, and melatonin. I also consent that any questions I have and management will go through the clinic staff. I understand that there is/may be an additional charge for visits outside of the scheduled/follow-up visits. *

3. CARE PROVIDERS - I understand that any recommendations and care received by Dr. Kristy Bailey are supportive only, and do not substitute for regular medical care. I understand that I must continue to see my regular Primary Care Provider as directed by them and take my regular medications as prescribed. *

4. MEDICAL HISTORY - I understand that I have the right to question any therapy proposed and/or provided by Dr. Kristy Bailey, and that all of my questions will be answered prior to receiving such treatment. I understand that I have not been and will not be given a guarantee of beneficial or specific results. I affirm that I have and/or will always, to the best of my ability, disclose my complete current and past medical history plus list my medication(s) to the clinic. I understand this history is essential for the clinic to be able to assess and provide competent care and treatment to me. I understand that the treatment I receive from Dr. Kristy Bailey is in large based upon my disclosures. *

5. PATIENT'S CONSENT - I have read and fully understand this consent form and realize my BHRT, TRT, Treatment, Rx/Prescriptions and all clinician time for consultations, plus any future consultations are all fee-based and are not covered by OHIP or insurance. I agree to pay the fee at the time of booking my consultation. *

6. LAB TEST NOTE - I understand that the majority of my Hormone Blood Lab Test panel is under OHIP where applicable. I understand some tests are not insured under OHIP and I incur all costs. *

7. CANCELLATION/RESCHEDULING FEES - I understand that I am responsible for full payment of services. I hereby acknowledge and accept full responsibility for any and all costs incurred. *

Disclosure/Liability Waiver

Within the medical community, there are opposing views with respect to the use of bioidentical hormonal replacement therapies. The use of bio-identical hormones is not recommended to be used to treat medical conditions, and is an off-label therapy used for symptoms of andropause, menopause, low energy, and mood symptoms. While numerous safety measures are taken by our health care providers and staff, incidental events may occur that are beyond the control of our staff.

For this, I (the Patient) understand that bio-identical therapy does provide true medical benefit, and is being used at our centre to lessen or treat non-life threatening symptoms you have identified as bothersome, undesirable, and unwanted. I also understand and am aware that there are a number of available prescription hormone replacement therapy I can receive from my regular provider (eg. Premarin, Prometrium, Climara, Estrace, Angeliq, Estalis, and Androgel). I have waived this decision and want to use bio-identical hormones from a compounding pharmacy to treat my symptoms.

It is therefore expressly agreed that you are voluntarily participating in this program and all bio-identical hormonal replacement regiments, and the use of any medications and/or supplements is undertaken at your own risk. You are voluntarily participating in this program and assume all the risks. You hereby agree to waive any claims or rights you might otherwise
have to pursue legal action against the treating/healthcare provider and staff involved for the effects of injury to you on account of involvement in the Bio-identical Hormone Replacement Therapy Program. You have carefully read this waiver and fully understand that it is a release of liability.

Patients Name *

First

Last

Patients Signature *

Today's Date *

Maintenance of Preventative Medicine and Cancer Surveillance

A requirement for acceptance and continuation in the Bio-identical Hormone Replacement Therapy Program is adherence to routine cancer screening. You must have routine physical examinations as indicated by your health conditions. Your signature below indicates that you will comply by obtaining the cancer/prostate screening from your primary care provider within six months of beginning the Bio-identical Hormone Replacement Therapy Program and then according to current screening guidelines, which can be obtained through and followed with your primary care provider. You also understand that all primary care services will be managed by your current primary care provider. At our centre, we will only be managing symptoms related to hormone deficiency.

I have read the above and all of my questions have been answered to my satisfaction. I attest that I have truthfully completed the health history intake form and have declared all of my known medical conditions. I accept all terms and conditions of this program and I am consenting to participate voluntarily in this program.

Patients Name *

First

Last

Patients Signature *

Today's Date *

Telemedicine Informed Consent Form

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patient when located at different sites.

I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
- If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
- I may revoke my right at any time by contacting FCP Dermatology at 416-861-8600.
I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
I understand that this document will become a part of my medical record.

Patient/Parent/Guardian Printed Name *

Patient/Parent/Guardian Signature *

Bio-identical Hormone Replacement Therapy Program Disclaimers

As discussed, the annual fee for the BHRT program is $8,800.

1) All consultations are subject to a $1000. non-refundable booking fee.

2) If you proceed with the program, the remainder of the annual fee is due at the first visit.

3) The consultation is NOT covered by OHIP or by private insurance.

Bio-identical Hormone Replacement Therapy Program Intake Form (M)

Personal Demographics

Primary Care Provider

Past Medical History

Specialists/Other Health Care Providers

Medications

Hormone Therapy History

Allergies

Family Health History

Cancer History

Social History

Exercise/Activity Level

Stress Experiences

Nutrition Practices

Sleep Practices

Overall Health Assesment

General Health History

Overall Health Assesment

General Health History Continued

Overall Health Assesment

General Health History Continued

Overall Health Assesment

General Health History Continued

MALE Health History

Has a healthcare provider ever diagnosed you with any of the following medical conditions? (Please check yes or no)

MALE Health History

MALE Systems Assessment

FEMALE Health History

Gynecological History

FEMALE Health History

Menstrual Period History

FEMALE Health History

FEMALE Symptoms Assessment

FEMALE Health History

FEMALE Symptoms Assessment

Bio-identical Hormone Replacement Therapy Program Treatment Consent Form

The form is to specify my consent for treatment with a combination of integrative treatments, custom compounded prescriptions, bioidentical hormone replacement, and off-label medications.

Disclosure/Liability Waiver

Maintenance of Preventative Medicine and Cancer Surveillance

Telemedicine Informed Consent Form

our treatments

Concerns

Contact Us