Florida Internal Medicine

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

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

Please enter your address and telephone number(s) below, IF CHANGED IN THE PAST YEAR:

Address Home phone Work phone Cell phone Preferred phone(s) to contact you Marital Status Any changes in your job or retired? Name, telephone & relationship of someone who can make medical decisions for you if you are unable: Have you prepared any of ADVANCED DIRECTIVE documents?

Lifestyle

Describe your diet Do you exercise? PERSONAL SAFETY: Check if you: Tobacco use in the past year. If you stopped, what year? Alcoholic beverages, how many per week? Do you take "recreational" or street drugs?

Medical History

Have you done any of these tests in the last 12 months? Other major medical tests in the past year, other than above Serious illness or accident in the past year Surgery or hospitalization in the past year (Women) GYN conditions in the past year: In the past 12 months, have you seen any of these healthcare providers: Any other doctors that you see, other than above Family member with medical illness or died in the past year

Medications

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

Immunizations

COVID-19 (coronavirus) If you have received an influenza (flu) 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

Body System Review

Do you use a method to prevent pregnancy GENERAL & NEUROLOGIC. Please check if you have... SKIN, HAIR & NAILS. Check if you have... EYES, EARS, NOSE & THROAT. Please check if you have... CHEST & HEART. Please check if you have... DIGESTION & BOWELS. Please check if you have... KIDNEY, BLADDER, GROIN & GENITAL: Please check if you have to ... SPINE & JOINTS. Please check if you have... Please check if you need help from another person ... During the past 2 weeks, how often have you had little interest or pleasure in doing things? In the past 2 weeks, how often have you felt down, depressed or hopeless? Please add any other medical problems or questions: