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Calla Slimspa Medical Weight Loss Center Patient Information
Personal Information
Today's Date
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First Name
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Last Name
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Date of Birth
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Gender
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Male
Female
Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone number we may use to reach you
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Would you like to provide an alternate phone number?
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Email Address
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Re-enter email address
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Emergency contact and phone number:
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Employer (enter "None" if not working)
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Occupation (enter "None" if applicable)
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How did you find us?
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Referred by a friend
Referred by a family member
Internet search
Other
Name of the person that referred you:
May we thank them for the referral?
Yes
No
Please explain how you found us:
Medical History
Do you have a primary care physician?
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Yes
No
Primary Care Physician Name and Phone Number:
Do you see any other medical care specialists?
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Yes
No
Please enter the following information about your specialist(s):
NAME - SPECIALTY - CONDITION BEING TREATED
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Please check any conditions or illnesses you have or have had in the past
Allergies
Asthma
Anorexia
Alcoholism
Arthritis
Anxiety
Atrial Fibrillation
Acid Reflux
Bullimia
Cancer
Constipation
Diabetes
Depression
Dug Addiction
Glaucoma
Hypertension
Heart Disease
High Cholesterol
Thyroid Problem
Insomnia
Kidney Problem
Other
Other
Do you take any over the counter medications? (ie: vitamins, ibuprofen, natural supplements, etc)
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Yes
No
Please list any over the counter medication you take.
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Do you take any prescription medication?
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Yes
No
Please list all the over the prescription medications you currently take (prescription and over the counter) and the condition for which you take it.
Example: Prilosec - acid reflux
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Do you have any allergies to medication or food?
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Yes
No
Please list any allergies you have to any food or medication
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Have you had any surgery in the past?
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Yes
No
Surgical history and year.
Example: Appendectomy - 1995
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Have you ever been hospitalized?
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Yes
No
List any hospitalizations and discharge diagnosis.
Example: Chest pain - diagnosis anxiety
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Does anyone in your immediate family have any of the following: Diabetes, Cancer, High Blood Pressure, High Cholesterol, Obesity, Thyroid Disease, or other significant illness?
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Yes
No
Family medical history.
Example: Mom - high blood pressure
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Social History
Please check all that apply:
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Smoking
Alcohol
Married
Divorced
Caffeine use
Frequent travel
Drug use
Eat out frequently
Eat mostly at home
Have children
Do not have children
Other
Other
Weight Loss History
How long have you been trying to lose weight?
What has been your highest weight?
What is your biggest obstacle in losing/maintaining your weight?
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Have you tried any other diet programs in the past?
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Yes
No
What other diet programs have you tried in the past?
Weight Watchers
Jenny Craig
Medifast
Transformations
Atkins
Nutrisystem
South Beach
HCG injections
Other
Other
By signing my name below, I am certifying that I have carefully answered each question truthfully and to the best of my ability.
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clear
444 W. New England Avenue Suite 121
Winter Park, FL 32789
407-644-7546