Florida Internal Medicine

Please fill out this form on-line, and then send to us by clicking Submit Form at the bottom of this page. DO NOT PRESS ENTER UNTIL YOU FINISH THE ENTIRE FORM. If you prefer to download the form to submit written answers, please click Home in the upper left, and use the "DOWNLOAD FORMS" link on the Home page.

Which provider are you seeing? Today's date * Name * Date of birth * E-mail address (optional)

Please enter your address and telephone number(s) below.

Street address * City * State * ZIP Code * Home phone Work phone Cell or mobile phone * Preferred phone(s) to contact you * Marital status What type of work do you do (or did, if retired)?

Protecting Your Medical Information

Name, telephone & relationship of someone who can make medical decisions for you if you are unable: Have you prepared any of these documents? * Who can we speak to about your medical conditions? Other person(s) who can be informed about your medical conditions

Lifestyle

Why are you seeking medical care? Describe your diet Do you exercise? Any tobacco use in the past year. If stopped, when? Alcoholic beverages, how many per week? Do you take "recreational" or street drugs? Personal Safety. Check if you...

Family Medical History

Please list any illness in parents, brothers or sisters Are any illnesses common in your family? (cancer, heart, stroke, diabetes, etc.)

Medications

List current medicines INCLUDING MG & DOSE & instructions to take them (or write "none") Allergy or adverse effects (or write "none")

Your Medical History

PLEASE ANSWER AS COMPLETELY AS YOU CAN; YOUR HEALTH MAY DEPEND ON IT.

Have you seen the following healthcare professionals in the past 12 months? Any other doctors that you see Serious illness or accidents Surgery or hospitalizations (Women) My last menstrual cycle began: (Women) My typical menstrual cycle is: Do you use a method to prevent pregnancy? (Women) Pregnancy:

Immunizations

COVID-19 (coronavirus) If you have received a flu (INFLUENZA) shot, enter the most recent year Have you received a PNEUMONIA shot? Have you received a "shingles" shot? If you have received a TETANUS or TDAP shot, enter the most recent year Any other immunizations as an adult?

Medical Tests

Please give the date (approximately) when you had your latest:

Pap smear or gynecologic exam (women) Prostate exam (men) HIV or AIDS test EKG or electrocardiogram Cardiac stress test Chest Xray Mammogram (breast x-ray) DEXA bone density x-ray Other X-ray, CAT scan or MRI (what kind?) Colonoscopy (flexible scope to examine lower bowel) Other medical tests, not mentioned above

Body System Review

Please check if you have any of these GENERAL or NEUROLOGIC symptoms Please check if you have any SKIN, NAIL or HAIR disorders Please check if you have EAR, NOSE or THROAT disorders Please check if you have CHEST, HEART or BREATHING complaints Please check if you have DIGESTIVE or BOWEL complaints Please check if you have KIDNEY, BLADDER, GROIN or GENITAL complaints Please check if you have SPINAL or JOINT complaints Over the past 2 weeks, have you had little interest or pleasure in doing things? Over the past 2 weeks, have you been feeling down, depressed or hopeless Do you need help from another person ... Please add any other medical problems or questions:

We evaluate potential patients to determine if they are good match with our practice & the services we offer. Completing office forms, providing patient records, obtaining laboratory or attending an appointment for an initial evaluation does not establish a practitioner-patient relationship. After the initial evaluation, individuals will be notified if they are accepted into the practice as a patient.