• Health Assessment For Medical Weight Loss

    by Florida Wellness and Medical Care
  • Date of birth*
     - -
  • Format: (000) 000-0000.
  • Gender*

  • For male patients, please mark the two questions bellow as “No” since they are not applicable.

    For female patients, please ensure the answers selected are accurate and reflect their medical history.

  • Are you currently pregnant?*
  • Do you plan to get pregnant in the next 2 years?*
  • Do you have any of the following chronic conditions or illnesses?*
  • Any family history of chronic illnesses or medical conditions? (e.g., diabetes, hypertension, cancer, stroke, hearth disease)*
  • Have you had a weight loss procedure in the past?*
  • Have you had any surgeries or hospitalizations in the past?*
  • Have you previously taken GLP-1 medications (Weight Loss Medications)?*
  • Are you currently taking any medications?*
  • Do you have any allergies? (e.g., food, medication, environmental)*
  • Do you have a history of pancreatitis?*
  • Do you have a history of gastroparesis?*
  • Do you have a personal or family history of Medullary Thyroid Cancer or MEN type 2 syndrome?*
  • Do you smoke?*
  • Do you consume alcohol?*
  • Do you use recreational drugs?*
  • Describe your diet*
  • How often do you exercise?*
  • In the past 12 months, have you completed any of the following medical procedures, tests, or assessments?*
  • Are you currently experiencing any of the following symptoms? (Check all that apply)*
  • Do you have any other health concerns or symptoms not listed above?*
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  • PATIENT CONSENT AND ACKNOWLEDGMENT

    By checking this box and signing below, I hereby acknowledge, understand, and agree to the following:

    1. Age and Accuracy of Information
      I confirm that I am 18 years of age or older. I certify that all personal, medical, and health information provided by me is true, accurate, and complete to the best of my knowledge. I understand that providing inaccurate, incomplete, or misleading information may result in delay, modification, or denial of treatment.
    2. No Guarantee of Treatment or Coverage
      I understand that completion of this medical assessment does not guarantee approval for treatment, issuance of prescriptions, insurance coverage, or specific medical outcomes. All treatment decisions are made at the sole discretion of the licensed medical provider based on clinical judgment and medical necessity.
    3. Medical Decision Authority
      I acknowledge that all prescriptions, medication selections, laboratory orders, dosing adjustments, and treatment plans are determined solely by the provider. I agree not to alter dosages, frequency, or discontinue medications without prior medical consultation.
    4. Off-Label Prescribing
      I understand that certain medications may be prescribed for off-label use when deemed medically appropriate and supported by clinical evidence and professional judgment.
    5. Compounded Medications
      I acknowledge that compounded medications are not FDA-approved products. These medications are custom-prepared by licensed compounding pharmacies in accordance with federal and state regulations. I understand the nature and purpose of compounded prescriptions when applicable.
    6. Laboratory Testing Requirements
      I understand that laboratory testing or other diagnostic evaluations may be required before or during treatment. Failure or refusal to complete medically necessary testing may result in delay, modification, or termination of care.
    7. Financial Responsibility
      I acknowledge that I am financially responsible for all services rendered, including any portion not covered by insurance (copays, deductibles, coinsurance, non-covered services, medications, supplements, or procedures). I understand that insurance coverage is not guaranteed.
    8. Telehealth Consent
      I consent to the use of telehealth services when applicable. I understand the nature of telemedicine, including its limitations, and agree to receive care through secure electronic communication platforms when deemed appropriate.
    9. HIPAA and Communication Authorization
      I acknowledge receipt of HIPAA privacy practices and authorize the clinic to communicate with me via phone, voicemail, SMS/text message, and email regarding appointments, medical information, billing matters, and treatment-related communications.
    10. Payment Disputes
      I agree to contact the clinic directly to address any billing concerns prior to initiating a payment dispute or chargeback with a financial institution.
  • By checking this box, I confirm that I have read, understood, and voluntarily agree to the terms outlined above.*
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