Calla Slimspa Medical Weight Loss Center Patient Information

Personal Information


Medical History

Please enter the following information about your specialist(s):
Please check any conditions or illnesses you have or have had in the past
Please list any over the counter medication you take. *
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 * 🛈
Please list any allergies you have to any food or medication * 🛈
Surgical history and year. Example: Appendectomy - 1995 🛈
List any hospitalizations and discharge diagnosis. Example: Chest pain - diagnosis anxiety
Family medical history. Example: Mom - high blood pressure 🛈

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. *
444 W. New England Avenue Suite 121
Winter Park, FL 32789