Restart Patient Form
Patient Name (First and Last):
*
DOB:
*
-
Month
-
Day
Year
Date
Current home address:
*
Phone number:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Preferred Pharmacy:
Are you currently exercising?
*
YES
NO
If YES: What activities?
*
How many days per week?
*
Occupation
*
Is your occupation physically demanding?
*
YES
NO
Work Address
Marital Status: (Please select one)
*
Single
Married
Widowed
Divorced
Spouse's information:
Name
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Personal Medical History (PMHx)
*
Heart Disease (CAD)
High Blood Pressure (HBP)
Diabetes (DM)
Stroke (CVA)
Cancer (CA)
Other (Please explain below)
Other:
Family Medical History (FMHx):
*
Heart Disease (CAD)
High Blood Pressure (HBP)
Diabetes (DM)
Stroke (CVA)
Cancer (CA)
Other (Please explain below:
Other:
G
P
A
Medications that you are currently taking:
*
Surgeries:
*
Allergies:
*
Do you use tobacco products?
*
YES
NO
How much: packs/day
*
Do you drink alcohol?
*
YES
NO
How often: days/week
*
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Myrtle Beach Diet Follow-up Form
Is there a reason why you stopped taking your medication(s)?
*
Is there a reason why you have not been back to our office?
*
Have you experienced any weight gain since you stopped taking your medication(s)?
*
Have you experienced any changes in your health since you last visited our office?
*
When you were on the diet medication(s), did you feel that it/they worked for you?
*
Have you been to see any other physician since you last visited our office? Y / N
*
Patient Signature:
*
Date:
*
-
Month
-
Day
Year
Date
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