Calla Slimspa Medical Weight Loss Center Patient Information

Personal Information

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Medical History

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
 
Please list any over the counter medication you take. *
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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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Please list any allergies you have to any food or medication * 🛈
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Surgical history and year. Example: Appendectomy - 1995 🛈
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List any hospitalizations and discharge diagnosis. Example: Chest pain - diagnosis anxiety
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Family medical history. Example: Mom - high blood pressure 🛈
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Social History

Please check all that apply: *
 

Weight Loss History

What other diet programs have you tried in the past?
 
By signing my name below, I am certifying that I have carefully answered each question truthfully and to the best of my ability. *
clear
444 W. New England Avenue Suite 121
Winter Park, FL 32789
407-644-7546