Florida Internal Medicine

Available Forms

1. NEW PATIENT MEDICAL HISTORY 2. INSURANCE & DEMOGRAPHICS - for all patients 3. ESTABLISHED PATIENT MEDICAL UPDATE 4. WEIGHT LOSS QUESTIONS - Nicole APRN only

4. WEIGHT LOSS QUESTIONS - Nicole APRN only

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 ON YOUR KEYBOARD 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.

Medically Supervised Weight Loss Program: Questions for NEW patients

By checking this box I accept that use of prescription medication as part of a weight loss program involves a risk of complications or side effects. *

Today's date *

(mm/dd/yyyy)

Name *

first name, middle initial & last name

Date of birth *

(mm/dd/yyyy)

E-mail address (optional)

This information is not released to third parties.

Preferred phone *

please include area code

Can this phone receive text messages?

Yes

How did you hear about us?

If referred by someone, who?

Please answer the following questions honestly so we can best help you reach your goals. We use your answers to individualize & safely prescribe your weight management program:

Who encoraged you to lose weight?

How important to you is it to lose weight?

What important reason, special occasion or goal date do you have to lose weight?

How many pounds would you like to lose?

How fast do you want to lose weight?

Can you commit to one office visit every 4 weeks? *

Yes

Have you attended any other weight loss centers?

Yes

If yes, which ones?

Please list any prescription medications you have used for weight loss: *

phentermine

phendimetrazine

diethylproprion

HCG

orlistat

thyroid hormone

Ozempic, Mounjaro, Wegovy injection

If you had side effects from any weight loss medication, please describe: *

What kind of diets have you tried on your own?

What is the longest you have been able to stick with a diet?

Does your family support your weight loss efforts?

Yes

Have you been advised by your doctor or healthcare provider to lose weight?

Yes

If yes, what is your healthcare providers name?

Do you eat because of emotions?

Yes

If you answered yes, please explain?

Which of the following describes your daily eating habits? (Please check all that apply):

3 meals with healthy snacks

3 meals

2 meals or less

Skip breakfast or other meals

Generally eat on the run

No regular eating pattern

Often crave sweets/carbs

Graze, small frequent meals

Vegetarian

Please describe any food allergies or special dietary requirements or restrictions *

Choose one that most closely describes your current level of exercise:

None

Light (1-3 times a week, easy pace, stretching, walking, etc.)

Moderate (2-3 times a week, moderate pace, some weights, etc.)

Heavy (3 or more days a week, vigorous pace, weights, fast running, etc.)

Alcoholic beverages, how many per week? *

None

1-2

3-5

6-7

More than 7 a week

Have you ever been under medical care for alcohol or drug addiction treatment? *

Yes

(Women Only): Are you pregnant, trying to become pregnant, or breast feeding?

Yes

(Women only): Are you using a method to prevent pregnancy?

Yes

What method?

Past or Present Health Conditions (please check all that apply); *

Have you or any member of your family had thyroid cancer *

Yes

Do you take any medicines or supplements? *

Yes

Have you or any member of your family had Multiple Endocrine Neoplasia *

Yes

Multiple endocrine neoplasia (MEN) syndromes are rare disorders of the endocrine system. They make patients more likely to develop benign (not cancer) or malignant (cancer) tumors in the endocrine glands. Sometimes the glands grow too large but do have not tumors.

Have you ever had pancreatitis? *

Yes

Pancreatitis is a painful inflammation in your pancreas, an organ in the middle of your abdomen.

Please list all medicines or supplements that you take: *

List both prescription AND non-prescription medicines

Do you have any medication allergies? *

Yes

Please list all allergies to medicines:

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.

* Required field