Johns Hopkins Executive Health
Appointment Date:
Please complete the patient information form within five business days of receipt and return via fax to
(410) 502-2400 for any questions, we can be reached at 410-955-9819 or Toll-free 888-544-1340
Title:
Mr.
Mrs.
Miss. Ms.
Dr.
Rev.
Name:
Address:
City, State, ZIP Code:
Home Phone:
Home Fax:
Work Phone:
Work Fax:
Email Address:
Date of Birth:
Social Security Number:
Gender:
Male
Female
Marital Status:
Single
Married
Divorced
Mother's Maiden Name:
Father's Last Name:
Employer:
Address:
Occupation:
Assistant/Contact:
Phone:
Preferred Method of Contact:
Home Phone
Work Phone
Emergency Contact:
Phone:
Personal Physician:
Physician's Address:
City, State, ZIP Code:
How did your hear about Executive Health?
1
Fax
Email
Medical History
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Back Pain
Bleeding Disorder
Cancer (Type)
Cataracts
Diabetes
Genetic Disorder
Glaucoma
Headache
Heart Disease
Heart Murmur
Hepatitis
Hearing Problems
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Lung Disease
Macular Degeneration
Neurological Disease
Pacemaker/defibrillator
Psychiatric Problems
Rheumatic Fever
Seizures
Sinus problems
Skin Cancer
Stomach/Intestine Problems
Stroke
Thyroid Problems
Tuberculosis
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Do you wear glasses or contact lenses?
No
Yes
Have you had any surgery?
If yes, please describe
No
Yes
Other
2
Name:
Family History
What illnesses, if any, run in your family?
Allergies
Are you allergic to any medications, food or dyes?
If yes, please list
No
Yes
Are you currently experiencing any medical problems?
If yes, please describe
No
Yes
Medications
Medications/Nutritional Supplements
Dose
Frequency
1
2
3.
4.
5.
6.
7.
8.
Personal Habits
Have you ever smoked?
Do your currently smoke?
Do you drink alcoholic beverages?
Do you drink caffeinated products?
No
No
No
No
Yes
Yes
Yes
Yes
Do you follow a modified diet?
If yes, please explain
No
Yes
Do you exercise regularly?
Type of exercise
Frequency
No
Yes
Immunizations
Have you had a flu shot this year (Oct-Feb)?
Have you had a tetanus shot within the last 10 years?
Have you ever received the pneumonia vaccine (pneumovax)
No
No
No
Yes
Yes
Yes
Not sure
Not sure
Optional Tests (Please select any optional test(s) you wish to include):
3
Exercise Stress Test
This treadmill test provides information about how your heart responds to physical activity. The test
consists of walking and possibly running on a treadmill in which the rate gradually increases in both
speed and elevation. A baseline test is recommended beginning at age 40 for patients with risk factors
for premature arteriosclerosis (diabetes, cigarette smoking, significant hypercholesterolemia, and
family history of heart attacks at a young age) and for those beginning a fitness program Others begin
at age 50. Whether or not it should be repeated requires individualized review with your Executive
Health physician.
Colonoscopy
A colonoscopy is recommended (in place of sigmoidoscopy) by the American Cancer Society to screen
for colorectal cancer in all Americans 50 years of age or older every 8-10 years Greater frequency of
colonoscopy is appropriate for patients with a family or personal history of colorectal cancer or polyps
This procedure requires thorough cleansing of the bowel and intravenous sedation An additional day
and a chaperone to accompany the patient home after the procedure is necessary
Travel Medicine
If your travel includes international destinations, we can arrange a consultation to discuss risks, update
travel immunizations, and provide appropriate prescriptions
Body Fat Analysis
Higher levels of body fat have been shown to be associated with numerous medical conditions,
including diabetes, heart disease, sleep apnea, and certain cancers. Measurements are taken to estimate
your current overall body fat
Exercise Counseling
A certified exercise counselor will work with you to create a customized exercise program
Recommended for patients who plan to start a regular exercise regimen or significantly change their
existing fitness routine.
Abdominal Aortic Ultrasound
This test is utilized to screen for enlargement of the abdominal aorta (aneurysm). Early detection can
potentially prevent the catastrophic consequences of aneurysm rupture We currently recommend this
test for patients over age 65 who have ever smoked, since cigarette use is strongly associated with the
development of aneurysms
Human immunodeficiency Virus (HIV) Testing
The Center for Disease Control (CDC) has recommended HIV testing for all adults under the age of 65.
Signed patient consent will be obtained prior to this blood test being sent to the laboratory
Arterial-Brachial index/Peripheral Arterial Disease (PAD) Screening
Patients with impaired blood flow to the legs (PAD) have been shown to be at high risk for heart
disease and stroke The American Heart Association currently recommends this test for all patients over
age 70, patients between 50 and 70 with a history of smoking or diabetes, patients under 50 with a
history of diabetes and one other cardiovascular risk factor (i.e., hypertension, high cholesterol, family
history of heart disease), and in patients with a history of heart disease or stroke
4
Additional Women's Services:
Gynecological Consult
Pelvic Examination & Pap Smear Only
Mammogram
A mammogram is advised as follows:
 Women in their40s should be screened at least biannually with mammography
 Women aged 50 and older should be screened annually
Our Breast Imaging Center offers breast examination and ultrasound if clinically indicated.
Bane Density Scan
To detect osteoporosis, this study should be obtained by women who are pert-menopausal and have not
been previously tested. Mild bone loss begins in the late 20's, but with the onset of menopause women
begin losing bone mass at the rate of 1-5% per year, putting them at risk for one of 1.5 million wrist,
hip and spinal fractures caused yearly by osteoporosis. The necessity for follow-up is determined by
individual's situation.
5
Johns Hopkins Executive Health
JOHNS HOPKINS PRIVATE CONTRACT FOR THE EXECUTIVE HEALTH
PROGRAM
I am (or other individual for whom I am responsible is) enrolled in_____________________________
(Health Plan).
I am voluntarily seeking medical services from Johns Hopkins Executive Health Program The services
I am seeking under the Executive Health Program could be provided to me outside of the Program and
some of the services I am receiving may be covered under the terms of my contract with Health Plan..
Not with standing the above, I am voluntarily entering into this Private Contract for the Executive
Health Program and am seeking such services under the Program for my convenience I acknowledge
that I will be solely responsible for the payment of the full amount of Johns Hopkins' charges for the
services rendered.
I also acknowledge that the charges for services provided by .Johns Hopkins through the Executive
Health Program will be in the range of $2,400 for the basic program and higher if optional services are
added (price structure attached). I also understand that my registration fee (if! do not cancel my
appointment in less than 10 business days) will be applied to the amount due. I also understand that
Johns Hopkins will not attempt to seek or accept payment from my Health Plan for the services under
this Private Contract inasmuch as I am fully responsible for the amount due to the Program.
My signature below indicates that I understand the above.
Signature
Printed Name
Address
Phone
Date
6
CREDIT CARD AUTHORIZATION FORM
(The following information is strictly confidential)
I authorize The Johns Hopkins Medical Institutions and affiliated providers to charge my credit card in
event of the following:
 If an open balance exists on my account after final charges have been posted for medical
services provided (This may occur because all up-front payments collected are based on
estimates only which may vary from actual final charges.)
 Failure to appear for an appointment without giving proper notice of cancellation at least 2
business days before the scheduled appointment. This cancellation fee is US$250 per
appointment.
 Failure to appear for an Executive Health appointment without giving proper notice of
cancellation at least 10 business days before the scheduled appointment. This cancellation fee is
US$400.
 As the amount previously collected is based on an estimated amount, there is a possibility a
balance could exist at the time of the final billing. In that instance, the Finance Department will
attempt to contact the patient prior to charging the credit card on file for any outstanding
balance via telephone or e-mail. If other payment arrangements need to be made, available
options can be discussed at that time.. In the event the Finance office is unable to reach the
patient, the credit card will be charged in accordance to the signed credit card authorization
form on file, and a statement will be forwarded to the patient via FedEx.
 FOR PATIENTS POSSESSING PRIVATE INSURANCE: I acknowledge financial
responsibility for any health insurance deductibles, co-insurance, or failure of any insurance
carrier to pay the hospital or physician's charges in full when rendered.. Johns Hopkins
Medicine may not participate with many insurance provider panels; in these situations
insurance companies may reimburse the patient or subscriber directly.
I acknowledge any deposit I make is based on Cost Estimate ONLY, and Actual Charges may vary
from the cost estimate. I acknowledge responsibility for any balance due between the Cost Estimate
and the Actual Charges.
American Express:
Master Card
Credit Card Number:
Exp Date
/
3 or 4 Digit # (security code):
Card Holder's Name:
Relationship to Patient:
Tel:
E-mail Address:
Card Holder's Billing Address:
Visa
Card Holder's Signature:
Date:
Patient Name:
JHH#:
7
Discover
PLEASE COMPLEIE THE INFORMATION FEQUESIED ABOVE AND FORWARD TO:
Johns Hopkins Medicine International, LLC
Attn: Name of Your Coordinator
601 North Caroline Street, Suite 1080
Baltimore, MD 21287-0735
For telephone of fax number, see below designated region
Main Reception Tel: 410-955-8032 Fax: 410-502-7397
Asia Pacific, Bermuda & N. America Tel: 410-614-5275 Fax: 410.502-5227
Corporate Relations Tel: 410-614-4331 Fax: 410-614-9150
Hopkins USA Tel: 443-287-6585 Fax: 443-287-6063
Latin America, Caribbean & Europe Tel: 410-955-3661 Fax: 410-502-7397
Middle East & Africa Tel: 410-614-4108 Fax: 410-614-8254
December 1 2006
8
Price Structure
The Executive Health visit is personalized for each individual patient. As such, the total cost for
services cannot be determined in advance. Additional testing or procedures may be requested by the
patient upon scheduling or recommended by the physician on the day of service.
- Medical History/Physical Examination
- Blood work & Urinalysis (includes PSA for males)
- Resting EKG - Chest X-ray
- Pulmonary Function Test
- Comprehensive Eye Examination (Wilmer Eye Institute)
- Hearing Test
- Nutrition Assessment
- Exit Conference with Physician
- Continental Breakfast, Hosted Lunch, Convenient Parking & Personal Representative
Executive Health Fee
$2,200 - $2,400
OPTIONAL (add to above price range):
Exercise Stress Test
Metabolic Stress Test
Ankle Brachial Index
$230.00
$400.00
$110.00
Body Fat Analysis
$25 00
Abdominal Aortic Analysis
$185.00
Mammogram
$508.00 (Screening)
$588.00 (Diagnostic)
Colonoscopy
GYN Consult
PAP Smear
$1,615.00
$200.00
$120.00
DEXA Bone Density Scan
$1200.00
Registration Fee
Priority Scheduling Fee
Rescheduling Fee
$400.00
$500.00
$250.00
Payment is expected at the time of service unless prior written arrangements have been made
through the Johns Hopkins International office U.S. dollars, personal checks or credit cards (AMEX,
MasterCard or VISA) are accepted.
A $400 registration fee is charged at the time the appointment is made. This will be applied
against the final bill. The registration fee will be refunded if the appointment is cancelled at least
10 business days in advance; otherwise, the fee will be forfeited in full.
As of 11/26/2007
9