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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
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Sex
*
Male
Female
Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What studies are you interested in? (select all that apply)
*
Alzheimers
Alzheimers Prevention
High Triglycerides
High Blood Pressure
Heart Attack/Stroke
Fatty Liver
Diabetes
Weight Loss
Chronic Kidney Disease
Cholesterol
COPD
Osteoarthritis
Are you a full time resident of Florida?
*
Yes
No
Mobile #
*
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Email
*
example@example.com
Race
*
Height (in)
*
Weight (lbs)
*
Ethnicity
*
Hispanic or Latino
Non-Hispanic or Latino
Do you have a primary physician?
*
Yes
No
Primary Physician
*
Primary Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Physician Phone Number
*
Please enter a valid phone number.
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
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Asthma
Yes
No
COPD/Emphysema
Yes
No
Chronic Bronchitis
Yes
No
Sleep Apnea
Yes
No
If other pulmonary not listed, please explain:
Cardiovascular
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Coronary Heart Disease
Yes
No
Heart Attack (Myocardial Infarction)
Yes
No
Percutaneous Coronary I (Stent)
Yes
No
Coronary Artery Bypass Surgery
Yes
No
Congestive Heart Failure
Yes
No
Atrial fibrillation
Yes
No
Stroke/Cerebral vascular disease
Yes
No
Carotid Artery Disease
Yes
No
Peripheral Artery Disease
Yes
No
Hypertension (High Blood Pressure)
Yes
No
Hypercholesterolemia (High Cholesterol)
Yes
No
Hyperlipidemia (High Triglycerides)
Yes
No
If other cardiovascular not listed, please explain:
Metabolic/Endocrine
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Thyroid Disease (Hypo)
Yes
No
Thyroid Disease (Hyper)
Yes
No
Diabetes: Type 1 IDDM
Yes
No
Diabetes: Type 2 NIDDM
Yes
No
Obesity
Yes
No
HIV
Yes
No
Dermatology
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Psoriasis
Yes
No
Eczema
Yes
No
Musculoskeletal
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Osteoarthritis
Yes
No
Chronic Low Back Pain
Yes
No
Osteoporosis
Yes
No
Osteopenia
Yes
No
Gout
Yes
No
Rheumatoid Arthritis
Yes
No
Fibromyalgia
Yes
No
If you have/had Osteoarthritis, where is it located?
Gastrointestinal
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Ulcers
Yes
No
Gastroesophageal Reflux Disease (GERD)
Yes
No
Heartburn
Yes
No
Irritable Bowel Disease
Yes
No
Crohn's Disease
Yes
No
Fatty Liver Disease
Yes
No
Hepatitis
Yes
No
Genitourinary
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Post-Menopausal
Yes
No
Chronic Urinary infections
Yes
No
Hematuria (blood in urine)
Yes
No
Chronic Kidney Disease
Yes
No
Kidney Stones
Yes
No
Erectile Dysfunction
Yes
No
Neurological
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Alzheimer's Disease Dementia/Cognitive Impairment
Yes
No
Peripheral Neuropathy
Yes
No
Parkinson's Disease
Yes
No
Migraine Headaches
Yes
No
Post herpetic neuralgia (Shingles)
Yes
No
Depression
Yes
No
Anxiety
Yes
No
Bipolar Disease
Yes
No
Insomnia
Yes
No
Post Traumatic Stress Disease
Yes
No
Heent
*
Yes
No
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
Glaucoma
Yes
No
Seasonal allergies
Yes
No
Do you have/Have you ever had Cancer?
*
No
Yes
Cancer
*
Type of Cancer
Start Date (mm/dd/yy)
Stop Date (mm/dd/yy)
Ongoing?
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
5
Yes
No
Family History
*
Yes
No
Relationship
Age Diagnosed
Ongoing?
Alzheimer's Disease
Yes
No
Demential or Cognitive Impairment
Yes
No
Heart Disease
Yes
No
Surgical History (enter dates if apply)
*
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)
Date Year
Reaction
Aspirin
Codeine
Morphine
Sulfa
Mycins
Penicillin
Tetracycline
If other Allergy, please explain:
Caffeine
Caffeine Intake
*
None
Caffeinated coffee, tea, or sodas
If yes, how many cups?
*
How often?
*
Daily
Weekly
Monthly
Occasionally
Alcohol
Do you drink alcohol?
*
No
Yes
How much Wine?
*
None
5 oz
8 oz
How often do you drink Wine?
*
Daily
Weekly
Monthly
Occasionally
Never
How much Hard Alcohol?
*
None
1 oz
2 oz
3 oz
> 3 oz
How often do you drink Hard Alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
How much Beer?
*
None
8 oz
12 oz
16 oz
24 oz
> 24 oz
How often do you drink Beer?
*
Daily
Weekly
Monthly
Occasionally
Never
Smoking/Nicotine
Do you smoke/use nicotine products?
*
No
Yes
Check all that apply
*
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?
Do you take any Medications?
*
Yes
No
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 Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
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