Healthcare Hookworm Form

Healthcare Hookworm Treatment Consent and Medical Questionnaire

Patient Information

Patient Name:

Male Female Other/Prefer not to say

Insurance Information

Medical History and Screening

Current Medications (include dose and frequency):

Known Drug Allergies or Other Allergies:

History of prior surgeries or hospitalizations (include dates):

Chronic medical conditions (e.g., diabetes, autoimmune disease, bleeding disorder):

Are you currently immunocompromised (including HIV or on immunosuppressive medication)?

Yes No

Are you pregnant, planning pregnancy, or breastfeeding?

Yes No

History of anemia or low hemoglobin?

Yes No

Hookworm Treatment Screening

Have you previously received helminthic therapy (e.g., hookworm) or other intentional parasitic exposure?

Yes No

Reason for seeking hookworm treatment and primary symptoms being treated:

Consent to provide stool samples and permit diagnostic testing and storage for clinical follow-up:

I consent to stool sample collection, diagnostic testing, and limited storage for clinical follow-up.

Procedure Description, Risks, Benefits, and Alternatives

Description: The proposed intervention involves controlled administration of hookworm larvae (or another specified helminth) for therapeutic purposes under clinician supervision. The treatment protocol, dose, and monitoring schedule will be determined by the treating clinician and documented in the medical record.

Known and foreseeable risks: I understand and acknowledge that hookworm administration carries risks including, but not limited to, local skin reaction at the administration site, gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhea), eosinophilia, iron deficiency or exacerbation of anemia, systemic allergic or hypersensitivity reactions (which can be severe), and the potential for unintended transmission to others. There are potential unknown or delayed risks, and long-term effects are not fully characterized. Individuals who are pregnant, immunocompromised, or have certain chronic conditions may face increased risks. I acknowledge that there is a possibility the treatment may not provide benefit.

Possible benefits and expected outcomes: Potential benefits may include modulation of immune response and improvement in selected symptoms; however, benefits are not guaranteed. The clinician will explain expected outcomes specific to my condition.

Alternatives: Alternatives to this treatment include standard medical therapies, symptomatic management, no treatment, and referral to other specialists. Refusal or withdrawal of consent will not affect my access to other medical care.

Patient Responsibilities and Follow-up

I agree to follow all pre-treatment and post-treatment instructions, attend required follow-up visits and laboratory testing, report adverse symptoms promptly, and refrain from blood donation or other activities advised by my clinician for the period specified. I understand I must inform the clinic of any change in health status, medications, pregnancy, or exposure to new medical conditions during the course of treatment.

Privacy, Data Use, and Authorization

I acknowledge that my medical information will be used for treatment, billing, and quality assurance. By signing below I authorize the release of my health information as necessary for treatment and payment and limited disclosures as required by law. Any use of specimens or data for research or publication will require my explicit additional consent, unless such use is de-identified under applicable standards.

Release for emergency contact or designated representative: I authorize disclosure of my treatment information to the following person(s) for care coordination purposes.

I acknowledge that I have received or been offered a copy of the Clinic's Notice of Privacy Practices and understand how my health information may be used and disclosed.

Consents and Signatures

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have had the opportunity to ask questions about the nature, purpose, benefits, and risks of hookworm administration and any alternatives. My signature below indicates my informed consent to receive the proposed treatment and to the clinical activities described above, including specimen collection and necessary diagnostic testing, unless I have indicated otherwise in writing.

I understand that I may withdraw my consent at any time by notifying the treating clinician in writing; withdrawal will not affect actions already taken in reliance on this consent.

Sign Now