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Myrtle Beach Diet Follow-up Form
How long ago did you stop taking your medication(s)?
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?
Are you on any new medications?
If yes, please list:
At Myrtle Beach Diet, we value your business and want to make it easy for you to refill your medications! Please be sure to inquire about our Mail Order Program if you live far away or have trouble getting into our office regularly. If you need someone else to pick up your medications for you, please ask for a Pre-Fill form.
Patient Signature:
Date:

MonthDayYear
Date

Rows	Mother/ father/brother/sister
Cancer
Heart disease
High blood pressure
Lung disease
Psychiatric disease

Women- Please answer:

Weight History:

Rows	Please Answer
Age of onset of weight problem
Number of weight loss attempts over last 5 years
Date of last weight loss attempt
Method
Outcome
Lowest weight 5 years:
Lowest weight 10 years:
Highest weight 5years:
Highest weight 10 years:
Women Current Dress size
Men current waist size

PLEASE READ CAREFULLY:

I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO NOTIFY DR. FOLEY OF ANY COMPLICATIONS OR UNUSUAL PROBLEMS THAT I AM HAVING WITH THIS PROGRAM AND IMMEDIATELY DISCONTINUE MEDICATIONS AND SUPPLEMENTS UNTIL DR. FOLEY REVIEWS MYSITUATION. I WLL NOTIFY DR. FOLEY IF MY HEALTH STATUS CHANGES FOR ANY REASON OR IF MY FAMILY DOCTOR PRESCRIBES MEDICATIONS OR ANY TREATMENT FOR ANY DISEASE OR ILLNESS PREVIOUSLY NOT REPORTED TO DR. FOLEY'S OFFICE ON MY PERMAMENT RECORD. I WILL INFORM MY FAMILY DOCTOR OF PRESCRIPTION MEDICATIONS I AM TAKING FROM DR. FOLEY. I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND WILL ASSUME FULL RESPONSIBILITY FOR RELATING MY MEDICATIONS TO DR. FOLEY. I AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS TO DR. FOLEY.
Signature
Date

MonthDayYear
Date
My Family Doctor:
Address:
Should be Empty:

Rows	YES	NO
Shortness of breath (at rest)
Shortness of breath (activity)
Night sweats
Productive cough
Bloody cough
History of tuberculosis
History of pneumonia
History of asthma
History of pulmonary embolism
History of emphtsema
Chest pain
High blood pressure
Heart attack
Angina
Heart failure
Heart murmur
Mitral valve prolapse
Low blood pressure
Edema
Peripheral vascular disease

Rows	YES	NO
Nausea
Vomiting
Abdominal pain
Black stools
Rectal bleeding
Heartburn
Belching
Constipation
Diarrhea
Hemorrhoids
Ulcer disease
Gallstones
Colitis
High cholesterol
High lipids
Nighttime frequent urination
Urgency
Difficult urination
Burning on urination
Infertility
Enlarged prostate (men)
Bloody urine
Recurrent urinary infection

Myrtle Beach Diet Follow-up Form