PREVENTATIVE MEDICINE INC

Patient's Name

Date of Birth

Address 1

Address 2

City

State

Zip

Email address

Cell Number

I agree to be contacted via email and or SMS with information related to your visit, post-visit satisfaction survey, appointment or check up reminders and billing

Emergency Contact Name

Emergency Contact Cell Phone

How were you referred to us ?

Do you have insurance?

Yes No

If yes, please provide receptionist with a copy of your insurance card and driver's license.

Are you Insured?

Yes No

If not, please provide insured's Information

Insured's Name

Insured Date of Birth

Relationship to Insured

1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Dr. Sepideh Moayed, M.D. and its associated physicians, clinicians and other personnel.

2. I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

HIPAA Authorization and Consent

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the disclosure of protected health information for treatment, payment, or healthcare operations (Sec 164.508 (a)).

I understand as part of healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care of treatment. I understand that this information serves as:

A basis for planning my care and treatment.
A means of communication among the health professionals who may contribute to my healthcare.
A source of information for applying my diagnosis and surgical information to my bill.
A means by which a third-party payer can verify that services billed were provided.
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand that as part of my care and treatment it may be necessary to provide my protected health information to another covered entity. I have the right to review this facility's notice prior to signing this
authorization. I authorize the disclosure of my protected health information as specified below for the purposes and to the parties designated by me.

HIPAA PRIVACY RULES OF PATIENT CONSENT AGREEMENT.

Consent to the use of and disclosure of protected health information for treatment, payment, or healthcare operations (Sec 164.506(a)) I understand that:

I have the right to review this facility's notice of information practices prior to signing this consent.
This facility reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I have provided if requested.
I have the right to request restrictions as to how my protected healthcare information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required b law to agree t the restrictions requested.
I may revoke this consent in writing at any time, except to the extend that this facility has already acted in reliance thereon.
It is the facility's procedure to share protected health information with las, X rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary protected health information for each transaction.

Patient's Name / Signature

Date

Consent to Use Telemedicine

Patient's Name

Doctor's Name

I am physically located in California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.
I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor's staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
If my doctor believes at any time that another form of service (for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.
I have the right to withdraw consent to the use of telemedicine services at any time and receive in-person healthcare services with my doctor.
I received an explanation of how electronic communications technology will be used for telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.
I agree to have the necessary computer, equipment, and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.
The laws that protect the privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to "auto remember" usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.
l agree to be videotaped and recorded during the telemedicine services. I understand the resulting images and audio will become part of my medical record.] OR [No part of the encounter will be recorded without my written consent.
I have the right to access my medical information and obtain copies of my medical records in accordance with California law.
I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance. I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction.

Patient's Name / Signature

Date

Patient Medical Record

Patient's Name

Date

Medications: (Current:) Please list any medications, pharmaceuticals, antibiotics, herbals, and supplements that you are currently taking.

Add Additional Medications

Medications: (Past:) Please list any medications, pharmaceuticals, antibiotics, herbals, and supplements that you have taken for an extended period of time in the past.

Add Additional Medications

Allergies: Please list any medications, food, seasonal, environmental & occupational allergies

Add Additional Allergies

Current Dietary Habits

Please list any specific diets that you are currently following, for example, Vegan (no dairy, meat, fish and eggs), vegetarian, Atkins, Paleo, DASH, raw, GAPS, etc.

Please list any specific diets that you have tried in the past.

Have you ever tried to strictly limiting your food intake, gone on liquid fasts, taken excessive laxatives or had binging episodes? Please describe briefly the time periods associated with these dietary habits.

What age is associated with your greatest and least weight?

Eating Behavior

Briefly describe your breakfast routine and typical food intake

Briefly describe your mid-day snack routine and typical food intake

Briefly describe your lunch routine and typical food intake

Briefly describe your mid-afternoon routine and typical food intake

Briefly describe your dinner routine and typical food intake

Briefly describe your late evening or after dinner snack routine and food intake

Adverse Childhood Experiences (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often or very often... Swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?

Yes No

2. Did a parent or other adult in the household often or very often... Push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?

Yes No

3. Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way? Or attempt or actually have oral, anal, or vaginal intercourse with you?

Yes No

4. Did you often or very often feel that... No one in your family loved you or thought you were important or special? Or your family didn't look out for each other, feel close to each other, or support each other?

Yes No

5. Did you often or very often feel that... You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Yes No

6. Were your parents ever separated or divorced?

Yes No

7. Was your mother or stepmother, often or very often pushed, grabbed, slapped, or had something thrown at her? Or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes No

8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

Yes No

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

Yes No

10. Did a household member go to prison?

Yes No

Now add up your "Yes" answers: This is your ACE store.
https://acestoohigh.com/got-your-ace-score/

Alcohol use Disorder Questionnaire

1. Do you lose time from work/school due to drinking/using?

Yes No

2. Is drinking making your home life unhappy?

Yes No

3. Do you drink because you are shy with other people?

Yes No

4. Is drinking affecting your reputation?

Yes No

5. Have you ever felt for Morse after drinking?

Yes No

6. Have you gotten into financial difficulties because a results of drinking?

Yes No

7. Do you turn to lower companions and an inferior environment when drinking?

Yes No

8. Does your drinking make you careless of your family's welfare?

Yes No

9. Has your ambition decreased since drinking?

Yes No

10. Do you create a drink at a definite time daily?

Yes No

11. Do you want a drink the next morning?

Yes No

12. Does your drinking cause difficulty with your sleep?

Yes No

13. Has your efficiency decreased since drinking?

Yes No

14. Is drinking jeopardizing your job or business?

Yes No

15. Do you drink to escape from troubles and worries?

Yes No

16. Do you drink alone?

Yes No

17. Have you ever had a complete loss of memory as a result of drinking?

Yes No

18. Has your physician ever treated you for drinking?

Yes No

19. Do you drink to build up your self-confidence?

Yes No

20. Have you ever been to a hospital or institution as a result of drinking?

Yes No

Substance Use Disorder

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Times Per Week

Frequency, Length of Use

Are you a recovering alcoholic? Please Explain.

Long-term use prescription/recreational drugs?

Do you crave sweets daily?

Do you use NutraSweet(aspartame?)

How many soda drinks do you consume daily / weekly?

Other Comments

Signature

Date

Your information will be encrypted.

PREVENTATIVE MEDICINE INC

HIPAA Authorization and Consent

Consent to Use Telemedicine

Patient Medical Record

Current Dietary Habits

Eating Behavior

Adverse Childhood Experiences (ACE) Questionnaire

Alcohol use Disorder Questionnaire

Substance Use Disorder

PREVENTATIVE MEDICINE INC.