Complete your medical history and we will call you to schedule your appointment

Complete your medical history and we will call you to schedule your appointment

Fill out the form below to provide your medical information and secure your appointment. This helps us determine your eligibility and ensures a smooth visit.
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Sex*

MaleFemale
Birthday*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What studies are you interested in? (select all that apply)*

AlzheimersAlzheimers PreventionHigh TriglyceridesHigh Blood PressureHeart Attack/StrokeFatty LiverDiabetesWeight LossChronic Kidney DiseaseCholesterolCOPDOsteoarthritisParkinsons
Are you a full time resident of Florida?*

YesNo
Mobile #*
Please enter a valid phone number.Format: (000) 000-0000.
Home #
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Race*
Height (in)*
Weight (lbs)*
Ethnicity*

Hispanic or LatinoNon-Hispanic or Latino
Do you have a primary physician?*

YesNo
Primary Physician*
Primary Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Physician Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referred By (Doctor Referral, Website, subject/patient, or other)*
Which PMR Event did you hear about us? (write N/A if not applicable)*
Your Health

Please review these health conditions/disease, check "Yes" or 'No" as they relate to your health and provide the dates

Respiratory*

Cardiovascular*

Rows	Yes	No	Start Date (mm/dd/yy)	Stop Date (mm/dd/yy)	Ongoing?
Coronary Heart Disease
Heart Attack (Myocardial Infarction)
Percutaneous Coronary I (Stent)
Coronary Artery Bypass Surgery
Congestive Heart Failure
Atrial fibrillation
Stroke/Cerebral vascular disease
Carotid Artery Disease
Peripheral Artery Disease
Hypertension (High Blood Pressure)
Hypercholesterolemia (High Cholesterol)
Hyperlipidemia (High Triglycerides)

Metabolic/Endocrine*

Dermatology*

Musculoskeletal*

Gastrointestinal*

Rows	Yes	No	Start Date (mm/dd/yy)	Stop Date (mm/dd/yy)	Ongoing?
Ulcers
Gastroesophageal Reflux Disease (GERD)
Heartburn
Irritable Bowel Disease
Crohn's Disease
Fatty Liver Disease
Hepatitis

Genitourinary*

Neurological*

Rows	Yes	No	Start Date (mm/dd/yy)	Stop Date (mm/dd/yy)	Ongoing?
Alzheimer's Disease Dementia/Cognitive Impairment
Peripheral Neuropathy
Parkinson's Disease
Migraine Headaches
Post herpetic neuralgia (Shingles)
Depression
Anxiety
Bipolar Disease
Insomnia
Post Traumatic Stress Disease

Heent*

Family History*

Rows	Yes	No	Relationship	Age Diagnosed	Ongoing?
Alzheimer's Disease
Demential or Cognitive Impairment
Heart Disease

Surgical History (enter dates if apply)*

Rows	Yes	No	Date (mm/dd/yy)
Appendectomy
Prostatectomy
Cholecystectomy
Herniorrhaphy
Partial Hysterectomy
Total Hysterectomy
Tubal Ligation
Vasectomy
Pacemaker
Spinal Stimulator
Mastectomy
Coronary Stent
Knee Replacement
Hip Replacement
Kidney Transplant
Bypass Surgery
Bariatric (Sleeve, Lapband, Gastric)

Are there any other past or current medical conditions/surgeries not listed? If yes, please list them here and include dates.

Allergy History (enter dates if apply)

Do you take any Medications?*

YesNo
Medications*
If more, please list here with additional information
Emergency Contact

Please list a contact person that may be reached in case of an emergency
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Signature*
Date*

MonthDayYear
Date
Should be Empty:

Rows	Yes	No	Year Started	# of packs per day
Cigarettes
Cigars
Pipes
Chewing Tobacco
Snuff
E-cigarettes
Patches
If not currently smoking, have you ever smoked?

Your Health