Greetings and Welcome Back! 6 And if you'd like to include ... · Thyroid Ultrasound • $ 205. An...

Greetings and Welcome Back!

We are very pleased to welcome you back to Scripps Center for Executive Health and your WholePerson Examination ™.

For more than 36 years, our physicians, lifestyle specialists, and administrative teams have dedicated themselves to a select group of patients who want the best in preventative health and early detection.

The following pages play an important role in getting ready for your WholePerson Examination. Our goal is to provide you the optimal healthcare experience. To help us achieve this goal, please complete all forms prior to your examination day. And if you'd like to include any optional imaging studies of lifestyle consultations, please call at least one week before your appointment dateto ensure availability.

It is our privilege to care for you. If you have questions or wish to discuss other details regarding your day, please call us at 858-626-4460 or 800-345-1130.

In Good Health,

Scott A. Carstens, M.D. James Tuck, MBA Medical Director Manager

Scripps Center for Executive Health 9850 Genesee Ave #520 La Jolla CA 92037 858-626-4460

TO PROVIDE YOU THE OPTIMAL HEALTHCARE EXPERIENCE, HERE ARE A FEW THINGS TO KEEP IN MIND

Upon check-in, all patients at Scripps are required to present two forms of identification,which must include:

1) Government-issued photo I.D.—driver’s license, Passport, Military I.D., AND

2) Any identification (credit card, social security card, etc.) with the same first and lastnames as they appear on the Government-issued photo I.D.

Complete all of the forms in this booklet and bring with you on the date of your exam. PleaseDO NOT MAIL OR EMAIL COMPLETED FORMS.

Women having mammograms: Bring your prior mammogram films for comparative studies.You may arrange to have prior films forwarded to Scripps Polster Breast Care Center or handdeliver to us at check-in.

If you have had lymph nodes removed and require special care during blood draw or when takingblood pressure, please contact our office before your exam date.

If you are allergic to latex, please contact our office before your exam date.

Smoking is not permitted in or around any Scripps facility, including sidewalks and parkingareas.

Scripps Center for Executive Health 9850 Genesee Ave #520 La Jolla CA 92037

Optional Procedures You May Want to Include

(Please call at least one week before your exam date to ensure availability)

Abdominal Aortic Ultrasound • $285An abdominal aortic aneurysm is a weakened, bulging spot in your abdominal aorta—the artery that runs through the middle of your abdomen supplying blood to the lower half of your body. An ultrasound is a high-frequency sound wave that reflects off body structures. The American College of Cardiology/American Heart Association recommend this for men 60-years-of-age or older with a first-degree relative who has had an abdominal aortic aneurysm.

Acupuncture ● $175

Each of us is a network of nutrients, substances, and energy or Qi (pronounced “chee”), which connects every organ and every part of the body. When the flow of Qi is disrupted or blocked due to disease, pathogens, or injury, pain or ill health result. By stimulating “acu-points” with the use of very fine needles inserted into the skin, our licensed acupuncturists can activate the body’s own natural healing mechanisms and restore balance to the flow of Qi. In 1997, acupuncture received a formal endorsement from the National Institutes of Health (NIH).

Cervical Cytology (Thin Prep) Pelvic Examination $90+

Cervical cytology provides an evaluation of gynecological health and is used to detect cancer of the uterus and cervix. The state of California recently passed “Business and Professions Code 655.6” which requires the patient or the responsible third-party payer be billed directly from the laboratory performing the cytological examination. Patients will receive a separate billing statement from San Diego Pathologists Medical Group for $125-200, depending on the type of cytological examination performed.

Colonoscopy $1550

Colonoscopy is recommended for persons 50 years of age and older for the early detection of colon cancer. However, if you are at increased risk for colon can cancer, your doctor may recommend having a colonoscopy at an earlier age. This outpatient surgical procedure requires a day to prepare, during which patients must stay on a liquid fast and take a prescription of half-lytely and bisacodyl tablets. The procedure is administered under “conscious sedation” and requires a responsible third-party upon check-out.

Comprehensive Eye Exam with Ophthalmologist $245

The eyes have it! Good eye health is essential to one’s overall well-being, which is why this 45-to-60 minute evaluation with your Scripps ophthalmologist includes an array of instruments, lenses, and bright lights to check the health of your pupil and retina for eye diseases. Your exam includes retinoscopy, refraction, cover test, slit lamp, dilation, and glaucoma puff test. You may also update your prescription for corrective lenses.


Optional Procedures (continued)

CT Chest (Lung Cancer Screen) $660

CT technology can detect small nodules when lung cancer is at its earliest and most curable state. This test is appropriate for current or former smokers and people exposed to second hand smoke or asbestos.

CT Coronary Artery Calcium Score $855

Coronary artery scanning using state of the art CT technology is a noninvasive test that can identify coronary arteriosclerosis (plaque) before the onset of heart damage. The scanner detects and quantifies areas of hard, calcified plaque and assigns a “score.” The higher the score the greater the risk for heart disease. Patients must avoid taking caffeine, alcohol, cough syrup, antihistamines, cold medications, and antacids for 12 hours prior to this test

Dexascan $507

Osteoporosis is a bone-thinning disease that leads to debilitating bone fractures. The Dual Energy X-ray Absorptiometry (DEXA) is an enhanced form of X-ray used to measure bone loss. Testing is recommended for men once at age 60 and women, especially at menopause. Bone loss in premenopausal women parallels that of men: 3-5% per decade. However, after menopause, bone loss can accelerate up to 3-5% per YEAR. Patients having a DEXAScan must stop taking Calcium and multi-vitamins 2 days prior to exam day. Any nuclear medicine studies or tests involving oral IV contrast must be completed one week prior to having a DEXAScan.

Genetic Risk Analysis for Focused Prevention • $875

Pathway Genomics’ genetic analysis services include a confidential, in-depth summary of your genetic predisposition for a variety of important health conditions such as breast cancer, colon cancer, type-2 diabetes, and heart disease, as well as personalized information on which medications work best for you. Also included in the services--unlimited access to genetic experts who will help you understand your results and what to focus on so you can take action.

Pelvic/Transvaginal Ultrasound $445

An ultrasound is a high-frequency sound wave that reflects off body structures. A pelvic/transvaginal ultrasound may be used to diagnose and assist in the treatment of a number of conditions including, endometrial conditions, fibroid tumors and cysts, and postmenopausal bleeding. You will be asked to drink several glasses of water or other liquid 1-2 hours before the procedure. Do not empty your bladder until the procedure is over.

Thyroid Ultrasound • $205

An ultrasound is a high-frequency sound wave that reflects off body structures. A thyroid ultrasound is an imaging method used to see the thyroid -- a gland in the neck that regulates metabolism. An ultrasound of the thyroid is often used to screen a lump in the neck, and to look for and monitor thyroid nodules.


Optional Procedures (continued)

Well Woman Cancer Antigen (CA-125) • $37

This blood test is recommended for females over 50. It is most effective for the early detection of ovarian cancer when tested in conjunction with a cervical cytology test, pelvic examination, and pelvic ultrasound.

Well Woman Hormone Assessment • $87

Hormone assessment is recommended for women concerned with menopause. It includes LH (Luteinizing Hormone), FSH (Follicle Stimulating Hormone) and Estradiol tests.


PREEXAMINATION PACKAGE TABLE OF CONTENTS

Payment and Scheduling................................................................................................................. 6

Occult Blood Test ........................................................................................................................... 7

How To Prepare .............................................................................................................................. 8

Medical History Questionnaire ....................................................................................................... 9

Mental Well Being ........................................................................................................................ 14

Physical Activity Questionnaire.....................................................................................................15

Life Quality Goal Setting .............................................................................................................. 16

Map To Scripps Center For Executive Health .............................................................................. 17

Hotels Near Scripps Center For Executive Health........................................................................ 18

6

PAYMENT AND SCHEDULING

INSURANCE The charges for services provided by Scripps Center for Executive Health (SCEH) are not billed to insurance and are due at the time of check-out. SCEH is not a Medicare provider and as such claims cannot be submitted to Medicare by SCEH or our patients.

CORPORATE ACCOUNTS

The services provided by SCEH are due at check-out the day of your visit unless your employer has a corporate account. In such cases, it is your responsibility to confirm with your employer, that you are eligible under established account guidelines. Scheduling and completion of medical services at SCEH does not constitute authorization for payment by your employer. If your employer determines that you are not eligible, all charges will be owed by you and are not billed to any insurance.

RESCHEDULING FEE: $100.00

You have one week preceding your examination date to make any date changes. Date changes made less than one week preceding your exam date may be done so for a $100 service fee.

LIFESTYLE CONSULTATIONS

As a courtesy to our specialists, we kindly request a notice of three business days should you need to cancel any individual lifestyle session.

PAYMENT Check payable to Scripps Center for Executive Health. We accept VISA, MasterCard, American Express or cash. Payment in full due at time of exam.

CHILDREN IN THE FACILITY

Scripps Center for Executive Health is an adult-only facility. Children may wait with a non-patient parent/legal guardian on levels 1 or 2 of the Scripps XIMED offices. Patients who arrive with children, in the absence of a responsible third-party, will be asked to reschedule their appointments.

CONSENT TO TREATMENT

I consent to the procedures that may be performed while an outpatient or, if necessary, during hospitalization. These may include, but are not limited to, emergency services, nursing care, laboratory procedures, X-ray examinations, medical and surgical procedures, anesthesia, or hospital services provided under the general and special instructions of the patient’s physician or surgeon.

CONSENT TO BLOOD TESTING

In the event of an exposure of blood or body fluids to a health care worker, I acknowledge that the patient’s blood will be tested for bloodborne viruses including Human Immunodeficiency Virus (HIV). The results of the test are necessary to determine whether the exposed health care worker needs immediate preventive treatment. The physician will inform the patient of the accidental exposure, test completion, and results.

I have read and understand the above. I agree to accept responsibility as described. I agree to be fully responsible for payment of this service and any related supplies, unless previous arrangements have been made by my employer.

_______________________________________ _____________________ Patient Signature Date


7

OCCULT BLOOD TEST (HIDDEN BLOOD IN STOOL)

TEST SLIDE WILL BE MAILED SEPARATELY BELOW IMMEDIA,

THIS TEST TAKES SEVL DAYS TO COMPLETE Complete this test even if you are having a colonoscopy.

Begin test no more than 5 days before your exam date.

Print your name and date sample was taken on container.

Bring the completed test to your exam. DO NOT MAIL.

Read test directions for further instructions.


8

HOW TO PREPARE

Please Follow These Instructions

Drink plenty of water

Take all regular medications

Do not eat or drink (except water) after 7:00 p.m. the evening before your exam

Wear or bring comfortable clothes (gym shorts, sweats, t-shirt)

Wear comfortable walking/running shoes (you may wish to bring flip-flops or slippers as well)

Wear or bring either a bra without underwires, a sports bra or a bathing suit top (women)

Do not apply body lotion or oil the morning of your exam.

* * * * * * * * *

Locker rooms, showers, towels, shampoo, hair dryers, etc. are provided for your convenience

* * * * * * * * *

Coffee, juice and snacks will be available in the morning after necessary testing is complete


9

MEDICAL HISTORY QUESTIONNAIRE

Age Name

Date of most recent physical other than at Scripps Executive Health:

Problems identified: Have these problems been resolved? Please describe:

Have there been any changes in your family medical history since your last exam?

If yes, indicate below: Ailment Family Member Age

High Cholesterol High Triglycerides Cancer (Type ) Stroke Heart Disease Diabetes High Blood Pressure Smoking Other

Since your last visit, have you had any new medical/health problems?

MEDICAL Chest Pain Cardiac or vascular

NeurologicAllergies

Respiratory (lungs) Hearing or vision Gastrointestinal Other

SURGERIES List type and date since your last evaluation

SKIN Yes No

Are you bothered by skin abnormalities? Have you had sunburns and/or high sun exposure? Do you have eczema, psoriasis, or other skin disorders? (circle which)

10

Have you had melanoma?

Have you had basal cell carcinoma?

Have you had squamous cell carcinoma?

Have you had actinic keratosis?

SLEEP Yes No

Do you notice excessive fatigue often?

Do you have difficulty getting to sleep or staying asleep? (circle which)

Do you experience or have you been told about snoring loudly enough to disturb the sleep of others?

Have you been told you have “pauses” in breathing or that you stop breathing during sleep?

Does your medical history include more than three awakenings per night (on average)?

MEN ONLY Yes No

Has the force of your urinary stream markedly decreased?

Do you notice any dribbling after stopping urination?

Have you noticed any discharge from your penis?

Have you been told of previous prostate trouble?

Do you have a significant decline in sexual interest?

Partial loss of erections? Complete loss of erections?

Erections only during sleep or early morning? Pain on ejaculation? Delayed ejaculation? Premature ejaculation? A "bulge" (hernia) in your groin?

Do you engage in sexual activity? How often?_____

11

Please Initial________ Scripps Center for Executive Health 9850 Genesee Ave #520 La Jolla CA 92037

WOMEN ONLY Yes No

What was the date of the first day of last menstrual period _______________ Are your periods regular with normal flow?

Do you ever bleed between periods?

Do you have vaginal itching or discharge? (circle which)

Have you ever taken birth control pills? Have you ever taken hormones?

Have you ever noticed any breast lumps?

When was your last PAP smear? Was it normal? Yes No Do you have hot flashes or night sweats? Have you had fibroids or endometriosis? (circle which) Have you had a significant decline in sexual interest?

Do you have pain on intercourse?

Do you feel you suffer from P.M.S. (pre-menstrual syndrome)?

Do you examine your breasts for lumps or changes monthly?

Do you engage in sexual activity? How often?_____________

CURRENT MEDICATIONS Please list medications. Include medical prescription(s), aspirin, over-the-counter remedies, herb(s), vitamin(s), and all other supplements. Include dosage and frequency.

Medication Dosage Frequency Since When?

_________________ _____________ _______________ ____________________

_________________ _____________ _______________ ____________________

_________________ _____________ _______________ ____________________

_________________ _____________ _______________ ____________________

_________________ _____________ _______________ ____________________

Anti-anxiety prescriptions

Psychotropic medications

Sedatives or sleep aids

Pain medications

12


DRUG ALLERGIES

List any known reactions to drugs (allergies or side effects) _____________________________

Are you allergic to latex Yes No

LIFESTYLE Indicate any changes in the areas below: Marital status Job Responsibility Children Family Illness/Death Social Support/Friends Personal Health Habits Other

SMOKING Yes No

Do you currently smoke? If yes, indicate which.

Cigarettes Packs per day

Cigars Per day

Pipe Bowls per day

Have you smoked in the past and quit? If yes,

What year did you quit? ________ What year did you start? ________

How many packs per day were you smoking when you quit? ________ Are you exposed to second hand smoke on a regular basis?

ALCOHOL Yes No

Has there been any change in your alcohol consumption?

Current drinks per week: ___Liquor (1½ oz/drink) ____Wine (3 oz/drink)

___Beer (12 oz/drink)

SUBSTANCE USE Yes No Frequency (day, week, month, etc.)

Marijuana __________ Cocaine __________ Amphetamines __________ Speed/Methamphetamines __________

13


CAFFEINE

Yes No

Do you drink coffee or caffeinated beverages? If yes, how many

Cups of coffee per day? ____

Caffeinated tea? _____

Caffeinated soft drinks?_____

Caffeinated energy drinks? _____

PSYCHOLOGICAL/EMOTIONAL Describe any symptoms:

14


MENTAL WELL BEING Give an immediate response to each question that best describes your current feelings. Do not think too long about your answers.

A 1. I feel tense or ‘wound up’: D 8. I feel as if I am slowed down:

___ Most of the time (3) ___ Nearly all the time (3) ___ From time to time (1) ___ Very Often (2) ___ A lot of the time (2) ___ Sometimes (1) ___ Not at all (0) ___ Not at all (0)

D 2. I still enjoy the things I used to enjoy. A 9. I get a sort of frightened feeling like ‘butterflies’ in the stomach:

___ Definitely as much (0) ___ Not at all (0) ___ Not quite so much (1) ___ Occasionally (1) ___ Only a little (2) ___ Quite Often (2) ___ Hardly at all (3) ___ Very Often (3)

A 3. I get a sort of frightened feeling as if something awful is about to happen:

D 10. I have lost interest in my appearance:

___ Very definitely and quite bad (3) ___ Definitely (3) ___ But not too bad (2) ___ I don’t take as much care as I should (2) ___ A little but it doesn’t worry me (1) ___ I may not take quite as much care (1) ___ Not at all (0) ___ I take just as much care as ever (0)

D 4. I can laugh and see the fun side of things: A 11. I feel restless as I have to be on the move: ___ As much as I always could (0) ___ Very much indeed (3) ___ Not quite so much now (1) ___ Quite a lot (2) ___ Definitely not so much now (2) ___ Not very much (1) ___ Not at all (3) ___ Not at all (0)

A 5. Worrying thoughts go through my mind: D 12. I look forward with enjoyment to things: ___A great deal of the time (3) ___ As much as I ever did (0) ___ A lot of the time (2) ___ Rather less than I used to (1) ___ From time to time, but not too often (1) ___ Definitely less than I used to (2) ___ Only occasionally (0) ___ Hardly at all (3)

D 6. I feel cheerful: A 13. I get suddenly feelings of panic:

___ Not at all (3) ___ Very often indeed (3) ___ Not often (2) ___ Quite often (2) ___ Sometimes (1) ___ Not very often (1) ___ Most of the time (0) ___ Not at all (0)

A 7. I can sit at ease and feel relaxed: D 14. I can enjoy a good book or radio or TV program: ___ Definitely (0) ___ Often (0) ___ Usually (1) ___ Quite often (1) ___ Not Often (2) ___ Not very often (2) ___ Not at all (3) ___ Very seldom (3)

Add the points for each A question. A Total: ____ Add the points for each D question. D Total: ____

15


PHYSICAL ACTIVITY QUESTIONNAIRE

EXERCISE

Describe your current exercise program by completing the chart below.

Type of Exercise Days Per Week

Length of Session

How Long? Years/Months

Location of Exercise, i.e., Home/Gym

Walk

Jog

Swim

Other Aerobic Activity:

Resistance Training

Other Physical Activity:

Golf

Yoga

PHYSICAL ACTIVITY Yes No Do you currently belong to a fitness facility? Do you have access to fitness equipment at your home or office?

Check any issues you would like to discuss with the exercise physiologist?

Low back care Aerobic activity Flexibility Weight/resistance training Knee and quadriceps strengthening Posture (proper ergonomics) Osteoporosis prevention Core Strengthening Aquatic Exercises Physioball Exercises Resistance Band Exercises Other _______________

What questions or concerns do you have about exercise in general or your specific program?

_____________________________________________________________________________

_____________________________________________________________________________

16


LIFE QUALITY GOAL SETTING

Please complete these statements with the first thought that comes to your mind.

* Maybe I don't need to anymore. (This should clarify what you would like to change).

* Maybe I do need to some more. (This should speak to what you would like to hang on to).

* Maybe I need to some time soon. (This should be a statement of future goals).

* Maybe I need to once again. (This recalls a resource from the past).

* Maybe I need to sometimes. (This should clarify an area where you need more flexibility).

* Anything else you would like to add?


17

SCRIPPS CENTER FOR EXECUTIVE HEALTH

Scripps XIMED Medical Center 9850 Genesee Avenue #520 La Jolla, California 92037

(858) 626-4460 or 1-800-345-1130

FROM INTERSTATE 5: FROM INTERSTATE 805: North or South North or South Take the Genesee Ave. exit. Take the La Jolla Village Dr. exit. Go East. Turn right at the stop- Go West. Turn right at Genesee Ave. light, “Scripps Hospital.” Turn left at stoplight, “Scripps Hospital.”

Once on the hospital campus, follow the drive straight to the T intersection and turn left. Turn right at the next stop sign. Take another right at the third stop sign. Follow the road to the parking structure on the right. Valet Parking opens at 8 a.m. We validate parking.


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HOTELS NEAR SCRIPPS CENTER FOR EXECUTIVE HEALTH

Should your plans include an overnight stay, we invite you to call any of the following nearby hotels.

(5-10 minutes away) Telephone

Estancia La Jolla 858-964-6525 9700 N. Torrey Pines Road La Jolla, CA 92037

La Jolla Marriott 858-587-1414 4240 La Jolla Village Dr. 1-800-228-9290 La Jolla, CA 92037

Doubletree Hotel Del Mar 858-481-5900 11915 El Camino Real Del Mar, CA 92130

Hilton La Jolla 858-450-4593 10950 North Torrey Pines Rd. La Jolla CA 92037

Hyatt Regency 858-552-1234 3777 La Jolla Village Drive La Jolla, CA 92037

(15-20 minutes away)

L’Auberge 858-964-6525 1540 Camino Del Mar Del Mar, CA 92014

Four Seasons Resort Aviara 760-603-6888 7100 Four Seasons Pt. Carlsbad, CA 92009

La Costa Resort 760-438-9111 Costa Del Mar Rd. 1-800-544-7483 Carlsbad, CA 92009

La Jolla Beach & Tennis Club 858-454-7126 2000 Spindrift La Jolla, CA 92037

La Valencia 858-454-0771 1132 Prospect La Jolla, CA 92037

http://www.estancialajolla.com/executive-health-center.php

http://www.laubergedelmar.com/

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