new patient welcome letter · 2019-12-19 · n am e: d ate: dear prospective new patient, please...

Name: Date:

Dear Prospective New Patient,

Please return the following prior to your appointment:

o Your completed information packet

o List of medications (if necessary)

o Recent labs/ EKG’s

o Front and Back copy of all insurance cards

o Government Issued ID

Return this information to us by fax or mail :

Secured FAX LINE (864) 558-0589

Doctor For Life

309 Tanner Road

Greenville, SC 29607

Please bring with you to your scheduled appointment:

· All Medication bottles

· Insurance cards

· Picture ID

· Form of payment other than check

With warmest regards,

Doctor for Life

REV: 042919

We want to thank you for your interest in Doctor for Life. Please find attached your new patient packet. We

ask that you complete your packet and return it to us as soon as possible to ensure a promptly scheduled

appointment. Please note your package will contain the necessary forms for your new patient intake as

well as a Fitness Assessment Evaluation. As part of the Doctor for Life Healthy Weight Lifestyle model, the

Fitness Assessment is a major part of your overall health evaluation and will help determine your fitness

level. Your visit with the physician, health coaches, dietitian, trainers are all part of the overall wellness

approach used at Doctor for Life.

309 Tanner Road, Greenville, SC 29607 | p: 864.640.0009 | f: 864.558.0589 | drforlife.com

Once we receive and process your information we will contact you to schedule your appointment. If you

have any questions or concerns, feel free to contact us at 864-640-0009. We are looking forward to meeting

you soon.

New Patient Welcome Letter

Patient Information

Last Name: Date of Birth:

First Name: Sex:

Address: Marital Status:

City: Social Security #: - -

State: Employer:

Zip: Emergency Contact:

Home Phone: ( ) Name:

Cell Phone: ( ) Relationship:

Work Phone: ( ) Phone: ( )

(Check BEST contact number above)

Insurance Information

Primary Insurance Carrier: Group Number:

Subscriber Number: Group Name:

Copay/ Co-Insurance: Deductible:

Secondary Insurance Carrier: Group Number:

Subscriber Number: Group Name:

Email Address: Ethnicity:

Race: Language

Preferred Local Pharmacy:

Preferred Mail Order Pharmacy:

Patient Photographs

Consent to Medical Treatment

(Please initial one option) I ___________ Consent I ___________ Do Not Consent

Patient Signature: Date:

Reviewed by: Date:

REV 0118


I understand that a picture Id or facial photo may be taken at the first visit and periodically thereafter for identification purposes only. It will be

considered as part of my medical chart and is subject to the same protection as the rest of my medical chart.

I consent to all treatment given under the general and special instructions of the attending physician. Treatment may include, but is not limited to,

diagnostic procedures, administration of anesthetics, use of prescribed medication, medical and physical therapy services, the collection and

utilization of cultures and laboratory specimens, and referral to specialty services for radiology, physician consultation, and other medical services, all

of which may be considered medically necessary or advisable in the judgment of the attending physician or their designees.

Patient Information

Name: Date:

Please specify the information we are allowed to disclose to the individuals if any. (Check all that apply)

Services rendered at this office (including participation in research studies)Office visit diagnosis, laboratory testing results, and/or diagnostic exams e.g. x-rays or ultrasounds resultsInformation regarding mental illness, substance abuse, or infectious diseasesMedications that are prescribed, stopped or changedScheduled appointments/ telephone confirmation of appointmentsMail Correspondence from our office, including Account StatementsEmail or text correspondence from our officeOther (Please Specify)

I authorize the following individual(s) access to this information as it pertains to my care or condition:

Name: Relationship: Phone:



Phone Number(s): Home Cell

Work Email :

Patient/ Reprensentative Signature:

Patient Name (print): Date:

REV: 0118


I authorize and permit Doctor for Life to disclose the following medical information pertaining to my care to the

individuals listed below.

I do NOT authorize Doctor For Life to disclose or release my medical information to anyone other than myself

except when required by law.

I authorize Doctor For Life to leave voicemails, send text messages , or send emails pertaining to my medical care

at the following :

I do NOT authorize Doctor For Life to leave voicemails, send text messages, or send emails pertaining to my

medical care. Communication will be through confidentially marked mail to your address.

This authorization is effective as the below signed date and shall remain effective until otherwise revoked in writing by

me. If you wish to revoke this authorization, you must do so in writing at Doctor For Life. If you choose to revoke this

authorization, it will become effective upon receipt but will not apply to disclosures previously made under consent. My

signature below acknowledges that a copy of the privacy practices followed by Doctor For Life is available to me

upon request.

HIPAA Personal Release Of Information

Information Release and / or Disclosure regarding patient:

Patient Name: DOB:

Address: Phone:

REQUEST my medical information FROM: SEND my medical information TO:

Provider Name: Provider Name:

Provider Office: Provider Office:

Street Address: Street Address:

City, State, Zip: City, State, Zip:

DURATION:

REVOCATION:

REDISCLOSURE:

SPECIFICATION:

Entire Medical Chart

Specified portion of medical chart pertaining to specific injury/ condition/or treatment

Laboratory Results

Mental Health

Alcohol and/or Substance use, abuse, treatment

HIV and Sexually Transmitted Disease Results

PURPOSE: Please circle the intended purpose of this request

Transfer of Care Individual Use Legal Reasons Insurance Purpose Other


Reviewed by: Date:

REV: 0118


I understand that the requestor may not lawfully further use or disclose the health information unless

another authorization is obtained from me or unless disclosure is specifically required or permitted by law.

Please indicate which type of information is to be released and or disclosed

Authorization for Release and/ Or Disclosure of Medical InformationTreatment, payment, enrollment and eligibility for benefits will not be conditioned on my providing or refusing to provide this

authorization.

I hereby authorize Doctor for Life, to release, disclose, or receive my medical information as indicated below to the healthcare

provider, entity, or person I have indicated. (A copy of this authorization is valid as an original.)

This authorization shall become effective immediately and shall remain in effect until

_________________________ or one year from date of signature, if no date entered.

This authorization may be revoked in writing by the undersigned at any time prior to the release of

information from the disclosing party. Written revocation will not affect any action taken in reliance on this

authorization before the written revocation was received.

Medical Record Request

Name: Date:

Top health concerns and barriers:The main things that you would like to fix or improve about your health:

The main things preventing you from improving your health:

Symptom ManagementThe main symptoms you wish to reduce or eliminate are:

Health Care ProvidersPlease list the providers that you are currently seeing (cardiologist, therapist, pulmonologist……).

Resources and supports

*Please list ALL medications with strengths and frequency (including vitamins and herbal products).

*ALLERGIES to medications or food:

REV: 0118 Initial: 1 of 3

Beside your health care team, who could you turn to for health related problems (family, friends, spiritual leader……)?

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Medical History

Medical History

Past Chronic Medical History – Please check all that apply.

Hypertension Diabetes High Cholesterol Cancer; Type:

Heart Attack Stroke Osteoarthritis; affected part(s)

Other Previous Diagnosis:

Past Surgeries – Please check if applicable and add the year completed.

Hysterectomy: Breast Surgery: Gallbladder:

Heart Surgery: Eye Surgery: Type: Prostate Surgery:

Other Surgeries:

Other Procedures – Please check if applicable and add the year completed.

Cardiac Catheterization: Arthroscopy: Other Procedures:

Past Hospitalization(s) Yes No

Date: Location: Reason:

Date: Location: Reason:

Family History – Please check all that apply.

Paternal Paternal Maternal Maternal

Father Mother Grandfather Grandmother Grandfather Grandmother Siblings Children

Alive

Deceased

Diabetes

Hypertension

Heart Disease

Stroke

Mental Illness

Cancer

Unknown

Type of Cancer or other illness:

REV: 0118 Initial: 2 of 3


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Medical History

Social History - Please answer the following questions.

Tobacco: Cigarettes Cigars Chewing Tobacco Snuff Never Used

How long have you used tobacco products? Years How many per day?

Quit Date (if applicable)

Alcohol: How many drinks per day?

What is the most number of drinks you have had at one time within the past year?

I do not drink

Illegal Drug Use: Please list any drug use (if applicable):

I certify that the information I have provided is true to my knowledge.


Reviewed by: Date:

REV: 0118 Initial: 3 of 3Page:


**Please feel free to attach any additional medical information, including medication lists and past medical

records. **

Name: Date:

Informed Consent to Obtain Medication History

Patient Acknowledgement


Reviewed by: Date:

REV: 0118

By signing this consent form you give Doctor for Life permission to collect, and give your pharmacy and

your health plan permission to disclose, information about your prescriptions that have been filled at any

pharmacy or covered by any health insurance plan. This includes prescription medications to treat AIDS/HIV

and medicines used to treat mental health conditions, such as depression. This information will become part

of your medical record and all applicable protected health information laws apply.

By signing below, I give permission for Doctor for Life to obtain my medication history from my

pharmacy, my health plans, and other healthcare providers for coordination of care and proper

medication management.


Doctor for Life utilizes an electronic medical record system in order to improve the quality of our services

given to our patients. Our system also allows us to collect and review your medication history. A medication

history is a list of prescription medicines that our physicians or other doctors have recently prescribed for

you. This list is collected from a variety of sources, including pharmacies and your health insurer. This list

does not include any over the counter medicines, supplements or herbal remedies. This information is

helpful in avoiding potentially dangerous drug interactions, as well as it allows the physician to closely

monitor proper medication adherence. An accurate medication history is very helpful and an important tool

in medication management.

Medication History Informed Consent

Name: Date:

Please verify that each section has been read by initialing in each box. Thank you.

REV: 042919 1 of 2

Prescription Meal Replacements: It is necessary that you have regular office visits with the physician to manage your program

progress. The physician determines how often you need to be seen based on the program you are under. In the event that you may

need products only you must call ahead to schedule a product pickup time. This will allow our staff to service you more efficiently.

DUE TO HEALTH DEPARTMENT REGULATIONS, ALL FOOD PRODUCTS ARE NON- RETURNABLE AND NON-

EXCHANGABLE.

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Payment for Service: Payment is due in full at the time service is rendered. We accept Cash, Visa, American Express, Discover &

MasterCard. We DO NOT ACCEPT CHECKS, or hold payments until a future date. We maintain the right to collect all payments

prior to service and/ or treatment being administered and/or prescriptions being written.

Insurance Verification: As a courtesy to our patients we obtain an insurance eligibility estimate for services rendered in our office.

We notify our patients that the eligibility is not a guarantee of coverage or payment. Any balance deemed patient responsibility,

after filing of insurance is expected to be paid in full prior to additional services. It is your responsibility to know the coverage of

your insurance policy and the expectations of your financial portion of your treatment.

Chronic Care Management: All Medicare patients eligible for Chronic Care Management (CCM) will be offered enrollment. CCM

is subject to co-pay and provides the following benefits in between your regular visits; Medication management without refill

charges, one year of refills for your maintenance medications, 24 hours a day access to your provider without an afterhours fee,

nutritional guidance, fitness guidance, coordination of care with your other providers, health coaching to support your healthy habits

and other support or resources that may be needed.

Collection of Balances: We maintain the right to transfer any outstanding overdue balance to an outside collection agency. The

agency may report any delinquencies to all major credit bureaus. Our office provides two statements to notify you of your balance

prior to transferring to a collection status. If your account goes into a collection status, you may be discharged from the facility.

Controlled Substance Prescriptions: If you are prescribed a controlled substance medication, our office requires a signed Provider

Treatment Agreement form and Medication History Consent form. We DO NOT CALL IN REFILLS FOR ANY CONTROLLED

SUBSTANCE. ALL CONTROLLED SUBSTANCES PRESCRIPTIONS ARE WRITTEN AT THE DISCRETION OF THE PHYSICIAN.

After Hours Care: If a physician returns a call after hours, for a message left on the after -hours answering machine, for an urgent

need from the on call physician, you may be billed an afterhours fee of $50.00. These charges are NOT filed to insurance. After-

hours fee N/A for CCM members.

Medication Refill Policy: Medication refills should always be requested at your appointments (please do not rely on your pharmacy

to request refills for you). The number of refills given will depend on the frequency of visits. Should you need a refill in between an

appointment, please allow up to 48 business hours to process that request and note that there will be a $15.00 fee per

prescription. Refill fee N/A for CCM members. Please bring ALL YOUR MEDICATION BOTTLES with you to each visit and the

pharmacy contact information that you prefer, so that we may accurately assist your medication adherence.

Office Policies

Office Policies

• .65 cents per page for the first 30 pages provided in an electronic format

• .50 cents per page for all other pages provided in an electronic format

• Clerical fee not to exceed 25.00 dollars for searching and handling

• Actual postage and applicable sales tax


Reviewed by: Date:

REV: 042919 2 of 2

Laboratory Services: It is your responsibility to know the coverage of your insurance policy and the expectations of

your financial portion of your treatment. We utilize LabCorp for our ordered lab work. It is your responsibility to know

the providers in your network. If you need to use a different lab please notify a staff member prior to treatment. Any

concerns relating to your LabCorp account are handled directly at LabCorp. Please call 1-800-845-6167 to speak with a

LabCorp representative.


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Completion of Medical Forms: There may be an additional fee for the completion of forms such as FMLA, disability

forms, Bio-Metrical Screenings, and handi-cap placards. Fees vary based on the individual form.

Copies of Medical Records: A physician, or other owner of medical records as provided for in Section 44-115-130 SC

law, may charge a fee for the search and duplication (The search and handling fee is permitted even though no medical record is

found as a result of the search, except where the request is made by the patient.) of a paper or electronic medical record, but the fee

may not exceed:

I have read, understand, and agree to these office policies, I acknowledge that at any time Doctor For Life has the right to

change and amend these policies. I understand that if I have a question concerning an office policy that a staff member will

happily assist me.

No Show Appointments Internal Medicine: You may be asked to pay a $30.00 fee for any Internal Medicine scheduled

appointment that was not cancelled or rescheduled at least 24 hours in advance. You will be responsible for this fee as

insurance companies do not cover these charges. You may notify the office of any cancellations by calling the office during

NORMAL BUSINESS HOURS. If you are 15 minutes or more, late to any scheduled appointment, you may be asked to

reschedule to a different date and time.

No- Show Appointments Weight Management: You may be asked to pay a fee of $50.00 for each Weight Management

follow up visit and $100.00 for all Initial Weight Management evaluations not cancelled at least 24 hours prior to the

scheduled appointment time may be charged to you. You are financially responsible for these fees. You may notify the

office of any cancellations by calling the office during NORMAL BUSINESS HOURS. If you are 15 minutes or more, late

to any scheduled appointment, you may be asked to reschedule to a different date and time.

Name: Date:

Notice of Assignment of Benefits to a Provider

Insurance Authorization and Assignment of Benefits


Reviewed by: Date:

REV: 0118


An assignment of benefits is an arrangement by which a patient requests that his or her health insurance benefit

payments be made directly to a designated person or facility, such as a physician or hospital.

Please be advised that the patient’s signature or, in the case of a minor or mentally handicapped individual, the

signature of a parent or legal guardian now absolutely provides for the assignment of benefits to Doctor for Life ,

authorizing this transfer of payment from the insured to the healthcare provider Doctor for Life .

By signing below, I herby absolutely authorize Doctor for Life t o apply for benefits on my behalf for services rendered

to me or my dependent(s) and request that payment(s) be made by my insurance company(ies) and that payments be

sent directly to Doctor for Life . I understand that it is the policy of Doctor for Life , to only bill insurance company(ies) if

they participate in that company’s network, and if they do not participate it will be my responsibility to bill my own

insurance company(ies) for reimbursement. I understand that I am to pay for those services rendered at time of service.

I certify that I (or my dependent(s)) have active and valid insurance coverage and have supplied Doctor for Life with the

most current and correct insurance identification card(s) as well as supplied Doctor for Life all necessary information

regarding the guarantor of the insurance policy(ies) and the necessary information regarding the subscriber(s) eligible for

insurance benefits which is required to submit medical claims for reimbursement. Failure to provide updates to any of

the information supplied within may result in denial of payment(s) to Doctor for Life and resubmitted claims with

corrected updated information that are still denied due to the fact that the corrected information was not supplied in a

timely fashion to Doctor for Life. I understand that I am financially responsible for all charges for medical services

rendered to me or my dependent(s) whether or not paid by insurance. I understand that this in no way relieves me of

my primary responsibility to pay for services rendered to me, and if my account is turned over to an attorney for

collection or taken to court, I agree to pay any collection fees, reasonable legal fees, court costs, and other expenses

incurred as a result of said collection or court date. I understand that Doctor for Life will report to commercial credit

bureaus only when an account becomes delinquent. Accounts having no payments within 30 days of the initial debt

notice are considered delinquent for payment purposes. Doctor for Life will report a delinquent account to the credit

bureau if they do not receive a timely payment. All delinquent accounts are reported as a "collection account" on the

consumer credit report. The debt will remain as a collection account while on the credit bureau report; however, any

subsequent payment activity is reported to the credit bureaus on a monthly basis.

I certify that the information I have reported with regard to my insurance coverage is correct and I hereby

authorize Doctor for Life , the release of any information relating to any claim for benefits, in order to process any

claim for benefits and to secure the payment of benefits. I authorize the use of this signature on all insurance

submissions. Furthermore, I permit a copy of this authorization to be used in place of the original. I may revoke

this authorization at any time in writing.

Insurance Assignment Of Benefits

Name: Date:

Dear Medicare patient,

Medicare will allow non-face to face encounters such as:- 24 access to the doctor on call- Telephone communication- Review of medical records and test results- Coordination and exchange of health information with other practitioners and providers.- Support from the staff in clarifying questions you may have- Medication refills and management- Timely referrals to Specialists Care- Questions about your laboratory results- Scheduling same day appointments- DFL goes beyond these benefits by offering group education classes in our culinary lab and fitness center

Patient Signature/ Verbal Consent: Date:

Reviewed by: Date:

REV: 0118


As your Primary Care physician, I am committed to serve you better as ever and will work very closely with your

insurance to meet their requirements.

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical

component of primary care that contributes to better health and care for individuals. Recently, Medicare made changes

in the way we coordinate your care with other health professionals and improve communication between the hospital

and other health facilities.

If you are a patient with two or more chronic medical conditions, you are eligible for a new program known as Chronic

Care Management. This will allow us to create an individualized comprehensive care plan for you to optimize your health

through patient education or motivational counseling, nutritional guidance and to achieve optimum physical function. All

these can be done without requiring a visit to your doctor.

Chronic Care Management would be considered a reasonable and necessary covered Medicare service. Medicare will

cover services during any month that we have provided at least 20 minutes of non-face to face encounters, subject to

co-pay as your only cost.

Our only goal is to provide you with the best optimal care and with your cooperation, together, we will achieve your

desired health goals. You have an option not to enroll and or to discontinue this service if you choose to. Majority of

others are already benefitting from these services since this program started in 2015.

Chronic Care Management

Notice of Privacy Practice

This notice of privacy practice describes how medical information about you may be used, disclosed, and how you can get access to this information. Please

review this document carefully. Patient Health Information (PHI) Under federal law is protected and confidential. Patient health information (PHI) includes

information about your symptoms, test results, diagnosis, treatment, and related medical information. Your patient health information (PHI) also includes payment, billing and insurance information.

How we use your PHI: This notice describes how we may use within our practice or network and disclose your PHI to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. We are committed to protect the privacy of your PHI.

This Notice also describes your rights to access and control your PHI. Under some circumstances we may be required to use or disclose your PHI without

your consent.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This

includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as

necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: We will use and disclose your PHI for payment purposes. For example, we may need to obtain authorization from your insurance company before

providing certain types of treatment. We will submit bills and maintain records of payments from your health plan. PHI may be shared with the following: billing companies, insurance companies (health plans), government agencies in order to assist with qualifications of benefits, or collection agencies.

Healthcare Operation: We may ask you to complete a sign-in sheet or staff members may ask you the reason for your visit so we can better care for you.

Despite safeguards, it is always possible in a doctor’s office that you may learn information regarding other patients or they may inadvertently learn something about you. In all cases, we expect and request that our patients maintain strict confidentiality of PHI. We may use and disclose your PHI to

perform various routine functions (e.g. quality evaluations or records analysis, training students, other health care providers or ancillary staff such as billing

personnel, to assist in resolving problems or complaints within the practice). We may use your PHI to contact you to provide information about referrals, for follow-up with lab results, to inquire about your health or for other reasons. We may share your PHI with Business Associates who assist us in performing

routine operational functions, but we will always obtain assurances from them to protect your PHI the same as we do.

Special Situations that DO NOT require your permission: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military

Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when

required by the Secretary of the Department of Health and Human Services. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces

personnel for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the Department of Veterans

Affairs of your eligibility for benefits, or to foreign military authority if you are a member of that foreign military services. In some situations, we may ask for your written authorization before using or disclosing any identifiable health information about you. If you sign an authorization, you can later revoke the

authorization.

Individual Rights:

You have certain rights with regard to your PHI, for example: Unless you object, we may share your PHI with friends or family members, or other persons

directly identified by you at the level they are involved in your care or payment of services. If you are not present or able to agree/object, the healthcare

provider using professional judgment will determine if it is in your best interest to share the information. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. We may

use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts. You may request restrictions on certain uses and disclosures of your PHI. We are not required to accept all restrictions. If you pay in full for a treatment or

service immediately, you can request that we not share this information with your medical insurance provider or our Business Associates. We will make

every attempt to accommodate this request and, if we cannot, we will tell you prior to the treatment. You may ask us to communicate with you confidentially by, for example, sending notices to a special address. In most cases, you have the right to get a copy

of your PHI. There will be a charge for the copies.

If you believe information in your record is incorrect, or if important information is missing, you have the right to request that we amend the existing information by submitting a written request. You may request a list of instances where we have disclosed PHI about you for reasons other than treatment,

payment, or operations. The first request in a 12 month period is free. There will be charges for additional reports.

You have the right to obtain a paper copy of this Notice from us, upon request. We will provide you a copy of this Notice at our facility. In an emergency

situation we will give you this Notice as soon as possible. You have the right to receive notification of any breach of your protected health information.

Health Information Exchange (HIE) is the electronic sharing of health information between participating providers in a way that ensures the secure exchange

of health information to provide care to patients. You have a right to opt-out of HIE participation. If you choose to opt-out, providers will not be able to search for your most recent health information when determining treatment. Opting out will not affect your ability to access medical care.

Our Legal Duty:

We are required by law to protect and maintain the privacy of your PHI, to provide this Notice about our legal duties and privacy practices regarding PHI, and to abide by the terms of the Notice currently in effect. We may update or change our privacy practices and policies at any time. You can also request a

copy of our Notice at any time. If you are concerned about your privacy rights, or if you disagree with a decision we made about your records, you may

contact the Privacy Officer listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. You will not be penalized in any way for filing a complaint.

Contact Person If you have any questions, requests, or complaints, please contact: Doctor For Life Attn: Privacy Officer 309 Tanner Rd. Greenville, SC

29607. Email: [email protected] HIPAA South Carolina US DHHS Atlanta Federal Center Suite 3B70 61 Forsyth Str.

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Fitness Assessment

Pretest Instructions

Yours to keep and use on your assessment day

Pretest Instructions

• Complete and sign the Informed Consent and Health Status Questionnaire

before arrival and bring it with you to the Fitness Assessment appointment

• Wear loose-fitting, comfortable clothing and athletic shoes

• Avoid heavy food, alcohol, and caffeine at least 3 hours before testing

o Can have an easily digestible, light snack 1-2 hours before

• Drink plenty of water 24 hours before

o At least 64 ounces

• Avoid strenuous exercise on the day of the Fitness Assessment

• Get at least 6-8 hours of sleep

• Feel free to bring a water bottle with you to the test

• Individuals prone to Hypoglycemia are advised to bring a light snack to eat

after the Fitness Assessment

• Upon arrival, check-in at the front desk, your trainer will meet you in the

lobby

Materials Copyrighted by Doctor For Life, LLC 2015 Duplication Prohibited Without Permission

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Fitness Assessment

Health Status

Questionnaire


This questionnaire is designed to identify adults whom physical activity might be inappropriate for, or, adults who

should have a professional medical evaluation in order to begin regular physical activity.

Personal Contact Information

Full Name: _________________________________________ Date of Birth: ________________

Additional Medical History for assessing fitness levels.

Please mark all of the statements that apply, or you have experienced.

Heart Health Status:

☐ Heart attack ☐ Heart Valve Disease

☐ Heart surgery ☐ Congenital Heart Disease

☐ Cardiac Catheterization ☐ Heart Transplantation

☐ Coronary angioplasty ☐ Heart Palpitations

☐ Cardiac Pacemaker ☐ Heart Failure

☐ Irregular Heartbeat ☐ Heart Murmur

☐ No known cardiac conditions

☐ You have a prescription for blood pressure medication(s) please list:_________________

Symptoms:

☐ Experience extreme breathlessness, unusual fatigue or dizziness during activities with

mild exertion

☐ Experience chest pain or discomfort with physical activity or mild exertion

☐ You are taking or are prescribed heart medication(s) please list:_____________________

☐ No Symptoms

Additional Health Issues:

☐ You have asthma, emphysema, COPD, or another lung disease

☐ You are a diabetic or take medication to control your blood sugar

☐ You have a burning or cramping sensation in your lower legs with minimal physical activity

☐ You currently have bone or joint problems, muscle cramps, or spasms, that could be made

worse by a change in physical activity please specify: _____________________

☐ You have had a recent injury or surgery in the last 3 months please specify: _________________

☐ You have additional concern(s) not listed please specify: _____________________

☐ No additional health issues Patient initial required: _______

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Fitness Assessment

Health Status

Questionnaire


Risk Factor Assessment:

☐ Male above the age 45

☐ Female above the age 55, and have had hysterectomy or are postmenopausal

☐ You smoke or have quit smoking within the past 6 months

☐ Your waist circumference is > 40 inches for males or 35 > for females

☐ Blood Pressure is > than 140 / 90

☐ You are physically inactive. < 30 minutes of Physical Activity 3 days of the week

☐You have high cholesterol. > 200 (or HDL is less than 34 mg/dl or LDL is > 169)

☐ You have an immediate family member who had a heart attack before age 55 (male) or age

65 (female)

☐ Other concerns or conditions:

☐ Can you swim unassisted? _____ Yes ______ No

Physical Activity Patterns and Objectives:

• Do you currently exercise? ☐ Yes ☐ No

• If yes, how many days per week do you exercise?

_____________________________________________________________________

• How many minutes per session?

_____________________________________________________________________

• List the type(s) of exercise or non-exercise physical activity that you do: (treadmill,

weights, sports, yard work, house chores, etc.)

_____________________________________________________________________

• List what you would like to accomplish with this exercise program: (burn fat, increase

muscle tone, increase energy, get stronger, etc.)

_____________________________________________________________________

By singing below you consent that you have been accurate and truthful in your responses to this

questionnaire. Your signature indicates that you have informed, Doctor for Life staff of any existing health

concerns and you understood that you are responsible for informing the staff of any changes as they occur.

Full Name (print): _____________________________________ Date: _________________

Signature: ________________________________________ __ Date: _________________

Reviewed By: ________________________________________ Date: _________________

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Fitness Assessment

Informed consent

• Reason for Test: To accurately assess your overall level of physical fitness, body composition,

cardiorespiratory endurance, muscular endurance and flexibility to safely and adequately

participate, with minimized risk for injury, in any recommended exercise program offered by Dr.

for Life.

• Assessments: Body composition will be determined by using the InBody or Body Composition

Analysis (BCA) tests. Cardiorespiratory endurance will be assessed with the 3-Minute Step Test.

Muscular endurance will be assessed by the Push Up Test. Flexibility is measured with the Sit-

And-Reach test.

• Risk and discomforts: The risks of the test procedures may include abnormal heart rhythms,

abnormal blood pressure response, shortness of breath, fatigue, and may rarely result in heart

attack. With our provided medical supervision, proper administration of testing and the

assessment of relevant health questions, every professional effort is made to minimized these

risks.

• Responsibilities of the participant: To complete the health status questionnaire and answer any

attendant health questions accurately. It is your responsibility to notify the test administrator of

any symptoms of discomfort or pain immediately during the test. You have the right to stop the

test at any point without penalty.

• Should I repeat tests at regular intervals?

o Yes! Repeating the tests regularly allows you to track your progress, stay motivated, and

modify your exercise program accordingly to maximize its benefits.

• How much does it cost?

o A fitness assessment is $75 and available to both patients and non patients.

By singing below, I (print name) _____________________________ do hereby consent to my participation

of the Fitness Assessment administered by Doctor for Life. I certify that I have provided true and

accurate information concerning my health status to the best of my ability. I acknowledge that the

benefits and risks of the assessment have been fully and reasonably explained to me. I understand that

the administrator may stop the test at any point If I meet any of the indications to terminate the

assessment. I fully understand my responsibilities and rights as the voluntary participant of this

assessment.

I fully consent and agree to participate in the Fitness Assessment at Doctor for Life. (Initial) ____

I do not consent or agree to participate in the Fitness Assessment at Doctor for Life. (Initial)_____

____________________________________ ____________________

Signature of Participant Date

____________________________________ ___________________

Signature of Administrator Date

new patient welcome letter · 2019-12-19 · n am e: d ate: dear prospective new patient, please...

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