• Restart Patient Form

  • Personal Medical History (PMHx):*
  • Are you currently exercising?*
  • Do you have any NEW medical problems (since your last visit)?*
  • Is your occupation physically demanding?*
  • Marital Status: (Please circle one)*

  • Spouse's information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you use tobacco products?*
  • Do you drink alcohol?*

  • BEAM LDX® Medical History Questionnaire

  • DOB:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • 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?*
  • Check YES if symptom is present, or if a history of the condition exists. Check NO if not.*
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  • History of: *
    Rows
  • Cardiovascular:*
    Rows
  • Gastrointestinal: *
    Rows
  • History of: *
    Rows
  • Genitourinary: *
    Rows
  • Musculoskeletal: *
    Rows
  • Neurological:*
    Rows
  • Other:*
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  • Family History: mother/father/brother/sister*
    Rows
  • Gastrointestinal: *
    Rows
  • History of: *
    Rows
  • Genitourinary: *
    Rows
  • Women:
    Rows

  • PLEASE READ THIS 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 MY

    SITUATION. 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. NORMAN’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.

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