Why Do I have to Fill-In this Medical Form?

Although many patients feel that having to fill out a new medical history form is unnecessary and annoying. It is a very important part of your medical care.

What is a medical history form and why is it so important?
Simply put a medical history form is an organized quick view of your past and present medical conditions, complaints, medications, and social history. It provides physicians with essential information that will be needed to treat you. Medical history forms may vary from office to office, however they all consist of basically the same sections:

Primary Concerns & Current Symptoms
This section is normally located near the top of the history form, or if your doctor's office has more than one page, it is typically on the first page. This is where you have an opportunity to explain to the physician and medical staff what parts of your health concern you and any symptoms you may be experiencing. When filling out this section, do your best to be as complete as possible. Try to remember to include: how long you have experienced the symptoms, the severity of the symptoms, and what makes the symptoms better or worse.

Review of Systems
This portion of the medical history form is the longest, and will list areas of the body that may or may not be related to why you are at the doctor. For example, an ophthalmologist (eye doctor) will list cardiovascular (heart) conditions and ask the patient to check which, if any, they have been diagnosed with. Having this information will allow us to not prescribe medications that will not interfere with any heart conditions. Most physicians' offices will utilize check boxes or ask you to circle yes or no for easy patient answering as there may be several conditions listed for each area of the body. Commonly there is a place in the review of systems section of the medical history form for you to write in any procedures or surgeries that you have had. The name of the physician or surgeon along with the dates of the procedures will also be required.

List of Medications and Allergies
We cannot stress sufficiently the importance of this section of the medical history form. Not only should this section be complete with all medications (prescription, over the counter, and homeopathic treatments) when you first fill out the form, but it should be updated at every visit with your doctor. It is important to include the dosage for each medication, when it is used (Ex: morning, afternoon, evening), and what it is used to treat. Since there are risks and benefits to each medication, treatment, and remedy, your provider needs complete and up-to-date medication information to prevent them from negatively interacting. Failure to disclose all medications could result in occasionally fatal situations.

Family Medical History
Many diseases and conditions are genetic, and because of this, your physician needs to know what you may be at risk of developing. If your doctor is aware of your risks, special attention can be paid to areas that are just generally reviewed. This is particularly true if you have no complaints.

Lifestyle Information
Don't let this section fool you, while it is typically the smallest section (depending on the medical office you are visiting) and located toward the end or bottom of the medical history form, it is very important. It is here that you will be asked personal questions related to: tobacco use, alcohol consumption, and sexual activities, among other things. Many times what we do in our private lives can have a tremendous impact on our health. If you have a problem with alcohol, illegal drugs, or other issues, failure to disclose this information could have serious repercussions if some medications or treatments are prescribed. Occasionally failure to fully disclose social behaviors may result in serious illness, injury, or death.

Patient Tip - Be Honest!
The social history portion of the family medical history form can be intimidating and occasionally embarrassing, but we as medical professionals are bound by law to keep all information you provide in relation to your health care confidential.

We Attempt To Lessen the Annoyance and Frustration of Medical History Forms
However without this information we have nothing to guide us, therefore If you do not have access to a computer, our office may fax you the form. With this medical history form provided ahead of time, we are able to customize your HRT program and you can fill it out on your schedule and be sure to include all of the vital information that is needed. Keep in mind that the medical staff is here to support and help you by providing the best medical care possible. As support staff, we realize that having to fill out the information may seem repetitive, but we ask that you understand that in order for our healthcare to be the best that it can be, the medical history form is a necessity and must be completed.

Patient's Informed Consent and Authorization for
Medical Care and Hormone Replacement Therapy

I, the undersigned patient (patient) hereby agree and expressly authorize to “HGH Medical Clinic of Puerto Vallarta” full authorization to secure a medical laboratory, medical doctor, physician and a dispensing facility, pharmacist, pharmacy, chemist and or an alchemist; to provide my diagnostic testing, medical care and if indicated, the dispensing of the prescribed pharmaceuticals based on my completed medical history form and any laboratory diagnostic tests obtained through “HGH Medical Clinic of Puerto Vallarta”.
I understand that HGH Medical Clinic of Puerto Vallarta shall pay such physician as an independent contracting physician, to render my medical services from funds I pay to HGH Medical Clinic of Puerto Vallarta. I further understand and agree that the independent contracting physician, and not HGH Medical Clinic of Puerto Vallarta, is rendering the medical care, services and treatment to me. HGH Medical Clinic of Puerto Vallarta is instructed and authorized to obtain the necessary medications prescribed by said medical doctor by causing them to be dispensed directly to me and/or sent to me by any pharmacy in Mexico or if possible by law into the country of my residence.
I specifically hold harmless and waive any and all claims or defenses against HGH Medical Clinic of Puerto Vallarta or the treating medical physician selected by HGH Medical Clinic of Puerto Vallarta; I also hold harmless and waive any and all claims or defenses against HGH Medical Clinic of Puerto Vallarta which is a licensed medical company, its directors, officers, shareholders, employees, agents, contractors, contracting physicians and contracting medical laboratories from any harm or injury I sustain from any act or omission of said treating medical doctor or other party(s).
I also hold harmless and waive any and all claims or defenses against any treating and prescribing medical doctor selected by HGH Medical Clinic of Puerto Vallarta to render medical services for and to me for any harm or injury I sustain as a result of treatment rendered by said doctor. I also hold said treating physician harmless and waive any and all claims and defenses for injuries or illnesses I sustain as a result of my failure to comply with the method of treatment and dosage schedule prescribed by said doctor or from my failure to disclose all relevant facts to said doctor. I agree to immediately cease any medical treatment prescribed by said medical doctor in the event of any adverse response or side effect(s) arising from the prescribed treatment and provide immediate written notice to HGH Medical Clinic of Puerto Vallarta and prescribing physician. I further agree to comply with all prescribing instructions and compliance on the use of medications.
I, the undersigned Patient, understand and acknowledge that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks or injury. I acknowledge that no promises, assurances or guarantees have been made to me as to the results of any diagnostic testing, analysis of said test results, examination of medical history or by any treatment given or administered by HGH Medical Clinic of Puerto Vallarta or any treating or prescribing medical doctor provided to me by HGH Medical Clinic of Puerto Vallarta.
I understand that the hormone blood level objective sought to result from my hormone replacement therapy, as prescribed by my treating medical doctor may be the highest level of standard reference range for my sex and age, or an even higher hormone blood level normally found in a person younger than myself. I understand that hormone replacement therapy for the purpose of elevating my hormone blood levels to the highest level of standard reference range for my age and sex, or above such range to the level of a younger person, “IS” experimental and may not render any benefits, but may result in unknown adverse results.
I am aware of the nature, risk, possible alternative methods of treatment, possible consequences, and possible complications involved in my treatment. I understand that recombinant human growth hormone replacement for adults involves the use of a medical drug approved for one purpose for a new and different purpose in an effort to obtain sought objective of medical treatment. Nevertheless, I consent to such care and treatment, and I execute this form with complete informed understanding and for the purpose of authorizing the medical doctor obtained for me by HGH Medical Clinic of Puerto Vallarta to administer to me for the relief of my body ailments and to enhance my physical condition and health. I also consent to receipt of any foreign-related versions of any prescribed drug approved for medical use in the country of Mexico. I understand that the methods of medical treatment offered or provided are not accompanied by any claims, guarantees or promises. I agree to present my photo identification at any time my blood is drawn pursuant to a HGH Medical Clinic of Puerto Vallarta test requisition.
I understand that medical information revealed by me may be used for continued medical research purposes, but that I will not be personally identified at any time. I understand that a prescribed drug ordered by me from HGH Medical Clinic of Puerto Vallarta may be dispensed to me by a pharmacy in the country of Mexico or if legally possible in my country of residence.
I understand that HGH Medical Clinic of Puerto Vallarta and their doctors obtained to provide medical treatment have elected not to carry any malpractice insurance due to the unique and unconventional medical treatments designed primarily to be preventative and non-invasive. With respect to any Mexican medical doctors rendering or prescribing my treatment at the request of HGH Medical Clinic of Puerto Vallarta this notice is provided pursuant to local legal Statutes as required by law and moral ethics here in Mexico.
I expressly agree that the jurisdiction and venue for any medical claim, legal or equitable claim or any type whatsoever, or any dispute regarding pharmaceuticals, physicians, physicians services, medical laboratories, or any services or products provided to me by HGH Medical Clinic of Puerto Vallarta its contracting pharmacies or any services rendered by any medical doctor it selects for me shall be by an exclusively binding arbitration in Guadalajara, Mexico.
I consent to the transfer and removal of any claim or action brought by me against HGH Medical Clinic of Puerto Vallarta, its physicians, contractors, medical laboratories, officers, directors, and share-holders to binding arbitration in Guadalajara, Jalisco, Mexico.
Further, I agree to pay all costs and reasonable attorney’s fees incurred by any party against whom I bring a claim or action in violation of the terms of this instrument or related to the transfer, removal, change of venue of any claim brought by my against any party to venue in Guadalajara, Jalisco, Mexico; as such costs are incurred on a weekly basis, without exception or assertion of any legal or equitable defense on my part or any legal counsel obtained to represent me. Jurisdiction and venue for any action brought against the Patient or its principal, by HGH Medical Clinic of Puerto Vallarta, its officers, directors, contracting physicians or laboratories in Mexico.
The pharmaceuticals and laboratories blood testing services supplied by HGH Medical Clinic of Puerto Vallarta, and medical services provided to me by treating medical doctors may or may not be covered or reimbursed by Medicare or other insurance. In any case, HGH Medical Clinic of Puerto Vallarta will not submit insurance claims on behalf of the patients.
In consideration of HGH Medical Clinic of Puerto Vallarta undertaking to render the undersigned patient any administrative or any other services in any way to this agreement, or HGH Medical Clinic of Puerto Vallarta disclosing information or methods of treatment to patient (either of which are deemed sufficient consideration for this agreement), then, in the event any court determines that the undersigned patient sought medical treatment or medical prescriptions through HGH Medical Clinic of Puerto Vallarta for possible or apparent purpose, directly or indirectly, of deception, assisting any investigation, or the rendering of any type of assistance to, or disclosing any information pertaining to HGH Medical Clinic of Puerto Vallarta, its procedures, officers, directors or medical protocols, to any news organization, possible or actual competitor, any type of governmental agency, any investigator or any other party for the possible or apparent purpose of securing any information, confidential or otherwise, about HGH Medical Clinic of Puerto Vallarta, it’s officers, directors, shareholders, affiliates, banking relationships, contractors, medical laboratories, contracting physicians, medical protocols, sources of pharmaceuticals, proprietary medical treatment protocols or HGH Medical Clinic of Puerto Vallarta’ system of pharmaceuticals procurement, distribution, and dispensing, then the undersigned Patient knowingly, expressly and irrevocably consents to a judgment in favor of HGH Medical Clinic of Puerto Vallarta, it’s officers or any party proceeding under the authority of this instrument, of liquidated damages, jointly and serially against the undersigned patient, as well as, any express or apparent principal of patient (including Patient’s employer) as an authorized or apparent agent of his principal or employer, in the amount of Ten Million Dollars, $10,000,000.00 which liquidated damage amount is hereby accepted by the undersigned as a reasonable amount for engaging in any such acts or deception and because they are difficult to ascertain. The undersigned patient engaged in such deception or any of the above described acts, agrees on behalf of himself and his principal, to pay all reasonable attorneys’ fees costs incurred by any person or entity to enforce this agreement. This agreement represents the complete and entire agreement between the parties to it.

We are the original suppliers of hGH to the 1st Anti-Aging clinic "El Dorado" in
Latin America - 1993