National Rejuvenation Centers
Medication Management Agreement
This agreement between _______________________ (patient) and National Rejuvenation
Centers establishes guidelines and conditions required for the use of bioidentical hormone
replacement therapy (BHRT) and any DEA “controlled” or “scheduled” medications. The Center
and patient agree that these guidelines and conditions are an essential factor in maintaining a
successful patient/practitioner relationship. Adverse side effects and/or physical /psychological
dependence may develop after repeated use of these medications and therefore, these agents are
prescribed with caution.
The patient accepts and agrees to the following conditions:
1. I understand that the medications I have purchased are prescribed for me based on
diagnosis derived from my submitted medical history, blood and lab work, and physical
examination. They are to be based exclusively for treatment of these diagnoses.
2. I will immediately report any adverse side effects related to the use of my medication to
the Center and discontinue use until advised to resume usage by the Center.
3. I will safeguard my medications from loss or theft.
4. I will not share, sell or trade my medications.
5. I agree that I will use my medication as prescribed, and will keep the medications in their
respective labeled containers
6. I will not attempt to obtain “scheduled” hormone replacement therapy medications
illegally or from any other health care practitioner without disclosing my current
medication usage. I understand that it is against the law to do so.
___________________________________________________________________________
Patients of The National Rejuvenation Centers
Patient Signature:______________________________
Date:______________________
National Rejuvenation Centers
Name:________________________________________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Email:_____________________________
Contact Number:____________________ Alternate Number:____________________________
SSN:______________________________ Emergency Contact:__________________________
DOB:_______________ Age:__________ Height:__________ Weight:____________________
Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Widowed
Gender: M
F
Number of Children:____________ Number of Pregnancies:_____________________________
Please mark an X in the Yes or No categories for the behaviors that apply to you.
Yes
No
( )
( ) Cigarettes ( ___ packs per day for ____ years)
( )
( ) Cigars
( )
( )
Chewing Tobacco
( )
( )
Alcohol – Frequency: ( ) Daily ( ) Weekly ( ) Occasionally ( ) Rare
( )
( )
Coffee: ____ cup (s)/pot (s) daily ( ) Regular ( ) Decaf
( )
( )
Tea:____ glasses per day ( ) Regular ( ) Decaf
( )
( ) Colas: ____ glasses per day ( ) Regular ( ) Caffeine free
( )
( )
Water: _____ glasses per day
Please circle on the scale from 1 to 10 the stress level of your occupation.
1
2
3
4
5
Laid Back
6
7
8
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10
Stressed to
the Max
What is your desired goal, or areas of concern?
National Rejuvenation Centers
Date of last: Colonoscopy:__________ First Day of Menstrual Period:_________
Bone Density:__________ Pap Smear:_________________________
P.S.A:________________ Breast Exam: _______________________
Rectal Exam:__________ Mammogram: _______________________
______________________________________________________________________________
Medical and Family History
Please mark an X for the answer that applies to each question.
Myself
1. Cancer
2. Diabetes
3. Heart Disease
4. Arthritis
5. Liver Disease
6. Elevated Cholesterol/Triglycerides
7. Endocrine Abnormalities
8. High Blood Pressure
9. Neurological Disease
10. Lung Disease
11. Kidney Disease
12. Stomach Disease
13. Bowel Disease
14. Blood Clots
15. Weight Control Problems
16. Osteoporosis/Osteopenia
17. Anemia
18. Alcohol Abuse
19. Drug Abuse/Recreational
20. Other
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
National Rejuvenation Centers
Please list all operations and surgical procedures, including plastic surgery:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
Serious injuries, accidents, hospitalizations and serious illnesses:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
Allergies to medications or foods:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
Please List all of your current prescription and over-the-counter medications and
supplements:
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
Name:____________________________ Dose (m/g):_____________ Times/Day:___________
National Rejuvenation Centers
Please mark an X in the Yes or No categories for that which applies to you.
Yes
No
( )
( )
Currently on a Specific Diet
________
Number of Meals per Day
( )
( )
Binge Eating
( )
( )
Compulsive Eating
( )
( )
Eating Disorder
Type:__________________
Females
Yes
No
( )
( )
Menstrual Problems
( )
( )
Premenstrual Tension
( )
( )
Endometriosis
( )
( )
Infertility
( )
( )
Vaginal Dryness, Discharge/Itching
( )
( )
Inability to reach orgasm
( )
( )
Lack of Sexual Desire
( )
( )
Breast Tenderness
Males
Yes
No
( )
( )
Prostate Problems
( )
( )
Prostate Surgery
( )
( )
Testicular Inflammation
( )
( )
Other Testicular Problems
( )
( )
Vasectomy
( )
( )
Impotence
( )
( )
Inability to Ejaculate
( )
( )
Lack of Sexual Desire
( )
( )
Decrease of Stamina
Other (Male or Female):__________________________________________________________
National Rejuvenation Centers
Hormone Deficiency Questionnaire
Signs and Symptoms
Low Mood/Depression
Hot flashes
Anxiety
Irritability/Anger/Aggression
Easily discouraged/Pessimism
Decreased interest in
activities/relationships
Decreased
initiative/motivation/drive
Decreased productivity at work
Concentration problems
Memory problems
Foggy thinking
Increased fatigue
Decrease in strength/stamina
Decrease in athletic performance
Decrease lean muscle mass
Muscle soreness/weakness
Body/Joint aches
Night sweats
Fat gain
Increased fat on hips/breast/thighs
Low blood sugar/Hypoglycemia
Sweet cravings (carbs)
Caffeine/Stimulant cravings
Salt cravings
Constant hunger
Elevated cholesterol
Elevated blood pressure
Digestive problems
Head or Body hair loss
Vaginal dryness
Dry/Thinning Skin
Fewer spontaneous morning
erections
Decreased libido
Erectile Dysfunction (ED)
Pain with ejaculation
Frequent need to urinate
Pain with urination
Blood in urine
Bone loss/osteoporosis
Mild
Moderate
Severe
Additional Comments
National Rejuvenation Centers
36081 U.S. Hwy 19 N.
Palm Harbor, Fl 34684
I acknowledge that I have received a copy of the Privacy Policy of The
National Rejuvenation Centers.
______________________
Patient’s Name (Printed)
______________________
Date
___________________
Patient’s Signature