Patient Details
Please take a moment to complete our New Patient Intake Form. All information is kept completely confidential.
Patient's Full Name
*
First Name
Last Name
Preferred Name
If different
Email
*
This is the name you identify with. Providing this allows the staff to address you properly.
Contact Phone Number
*
Please provide at least one phone number. Your mobile number can be used to look up your account
Alternative Phone Number
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Day
-
Month
Year
Sex
*
Male
Female
X
Drivers License Number and State
*
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
How did you hear about us?
Friend/ Family
Existing Patient
Physician/ Specialist
Online Ad
Web Search
Other
Florida Health Care News
Facebook/ Instagram/ LinkedIn
Referred by:
Who were you referred to?
Spartan Medical
Infinity Medical Institute
Mike Montemurro
Kat Montemurro
Donna Trembly
Sherice Reddick
Heidi Hurter
Dr. Moriah Moffitt
Back
Next
Save
Questionnaire
Marital Status
Single
Married
Seperated
Divorced
Do you smoke?
Yes
No
Do you drink alcohol?
Socially
Moderately
Heavily
N/A
Do you exercise?
1-3 days per week
3-4 days per week
5 or more days per week
N/A
Have you ever used steroids for body building?
Yes
No
List all known allergies (type N/A if unknown)
*
Do you have bleeding disorders?
Yes
No
Are you taking Aspirin, blood thinners, or fish oil?
Yes
No
Other
Do you you have cancer or a history of cancer? (if yes, please explain below)
Yes
No
Explain here
Do you you have heart disease or a history of a heart attack?
Yes
No
Do you have high blood pressure?
Yes
No
Do you have low blood pressure?
Yes
No
Do you have low testosterone?
Yes
No
Do you have a history of seizures?
Yes
No
Have you had surgery?
Please list all surgeries with approximate dates within the past 5 years.
Are you taking medication?
*
Please list all current medications and doses.
Are you taking vitamins or supplements?
Please list all current vitamins/ supplements and doses.
Back
Next
Save
Family History
Fill all that apply
Family history of heart attacks/ strokes?
Family history of cancer?
Family history of blood clots?
Family history of high or low blood pressure?
Other
Back
Next
Save
Women Only
Fill all that apply
Do you have a still have periods?
Yes
No
Date of last period
Using birth control? If yes, what method?
Have you ever been pregnant? If yes, how many times?
How many live births have you had?
Do you have poly-cystic ovaries?
Yes
No
Have you had a hysterectomy?
Yes
No
Have you had your ovaries removed?
Yes
No
Do you have a history of abnormal pap smears?
Yes
No
Last Mammogram
Date - estimate
Back
Next
Save
Medical Aesthetics History
Have you had any of the following procedures?
Cosmetic neuromodulators (includes Botox, Dysport, and Xeomin)
Yes
No
Cosmetic fillers
Yes
No
PDO threads
Yes
No
Laser resurfacing
Yes
No
Back
Next
Save
Are you interested in hearing more about...
Please select all categories you would like to discuss at your next appointment
Weight Loss Treatments
Bioidentical Hormone Replacement Therapy
Sexual Health and Enhancements
Peptides
Botox and/or fillers
ED Treatments
PRP Therapy
PDO Thread Face/Neck Lift
Back
Next
Save
Current Symptoms
What are your CURRENT symptoms? 0 means you have no symptoms of this type at all. 1 means you have very mild symptoms of this type. 4 means moderate symptoms. 7 means you have severe symptoms of this type.
Sleep disturbance
*
1
2
3
4
5
6
7
Depression
*
1
2
3
4
5
6
7
Irritability
*
1
2
3
4
5
6
7
Anxiety
*
1
2
3
4
5
6
7
Mood swings
*
1
2
3
4
5
6
7
Migraine headaches
*
1
2
3
4
5
6
7
Palpitations
*
1
2
3
4
5
6
7
Painful intercourse
*
1
2
3
4
5
6
7
Night sweats
*
1
2
3
4
5
6
7
Hot flashes
*
1
2
3
4
5
6
7
Dry skin
*
1
2
3
4
5
6
7
Chronic fatigue
*
1
2
3
4
5
6
7
Restless leg syndrome
*
1
2
3
4
5
6
7
Hair loss
*
1
2
3
4
5
6
7
Fatigue
*
1
2
3
4
5
6
7
Weight control
*
1
2
3
4
5
6
7
Low sex drive
*
1
2
3
4
5
6
7
Erectile Dysfunction
*
1
2
3
4
5
6
7
Poor focus
*
1
2
3
4
5
6
7
Body aches/ joint pains
*
1
2
3
4
5
6
7
Memory lapses
*
1
2
3
4
5
6
7
Exercise intolerance
*
1
2
3
4
5
6
7
Loss of muscle tone
*
1
2
3
4
5
6
7
Patient comments or any changes in medical history since last report.
Signature
*
Today's Date
Save
Submit
Should be Empty: