Apply for financing Book Now

Home
About us
Non-Surgical
Breast & Body
Health & Wellness
Exclusive VIP Membership | Clearwater Aesthetics – Unlock Premium Benefits!
Shop
- Orders
Payment Plans

Weight Loss New Patient

Step 1 of 4

25%

We would like to formally welcome you to our practice! We look forward to being your providers for both medical and aesthetic needs.
In order to provide the best care possible, we need to collect some information about you. If you have any questions or concerns - please do not hesitate to ask!

WELCOME!
The team at Clearwater Primary Care & Aesthetics
(Florida Family Medical Center)

Name(Required)

D.O.B(Required)

MM slash DD slash YYYY

Age(Required)

Gender(Required)

Male

Female

Primary Language(Required)

Translator Needed

Yes

No

Purpose of initial visit(Required)

Weight (in Pound)(Required)

Height (in cm)(Required)

Do you have any ALLERGIES?

Drug Allergies(Required)

Aspirin NSAIDS Penicillin Sulfa Contrast Dye Iodine

None

Food Allergies(Required)

Peanuts Soy Wheat Tree Nuts Shellfish Fish Strawberries

None

Environmental Allergies(Required)

Latex Bees Wasps Cats Dogs Grass Pollen

None

Are you in good health at the present time of the best of your knowledge ?(Required)

Yes

No

If no, please explain(Required)

Are you under a doctor's care at the present time ?(Required)

Yes

No

If yes, whom and for what?(Required)

Name of preferred pharmacy?

Location

Do you take any medications or supplements on a daily basis? If yes please list below:

Name

Strength

How Often ?

PAST MEDICAL HISTORY

Do you now and ever had:

Diabetes

High blood pressure

High cholesterol

Hypothyroidism

Goiter

Cancer

Leukemia

Psoriasis

Angina

Heart Problems

Sleep apnea

Emphysema

Heart murmur

Pneumonia

Pulmonary embolism

Asthma

Stroke

Epilepsy (seizures)

Cataracts

Kidney disease

Kidney stones

Crohn's disease

Colitis

Anemia

Jaundice

Hepatitis

Stomach or peptic ulcer

Rheumatic fever

Tuberculosis

HIV/AIDS

PID

Other medical conditions (please list):

Surgery / Procedures History:(check all that apply)

Appendix

Bladder Suspension

Blood vessel surgery

Arteries

Veins

Cesarean Section

Colon / Rectal surgery

Dental surgery

Ear surgery

Eye surgery

Gallbladder

Heart Procedure / Surgery

Bypass

Heart valve surgery

Cardiac Ablation

Angioplasty (balloon)

Cardiac Stent

Defibrillator

Pacemaker

Hernia Repair

Hysterectomy Complete

Hysterectomy Partial

Joint replacement / Orthopedic surgery

Ankle

Back

Hip

Knee

Neck

Shoulder

Wrist

Other

Kidney surgery

Organ transplant

Prostate surgery

Thyroidectomy

Sinus surgery

Tonsils and / or adenoids

Tubal Ligation

Vasectomy

Aesthetics / Plastic surgery

SYSTEMS REVIEWS

In the past month, have you had any of the following problems ?

GENERAL

Recent weight gain

Recent weight loss

Fatigue

Weakness

Fever

Night sweats

NERVOUS SYSTEM

Headaches

Dizziness

Fainting or loss of consciousness

Numbness or tingling

Memory loss

STOMACH AND INTESTINES

Nausea

Heartburn

Stomach pain

Vomiting

Yellow jaundice

Increasing constipation

Persistent diarrhea

Blood in stool

Black stools

PSYCHIATRIC

Depression

Excessive worries

Difficulty falling asleep

Difficulty staying asleep

Difficulties with sexual arousal

Poor appetite

Food cravings

Frequent crying

Sensitivity

Thoughts of suicide / attempts

Stress

Irritability

Poor concentration

Racing thoughts

Hallucinations

Rapid speech

Guilty thoughts

Paranoids

Mood swings

Anxiety

Risky behavior

MUSCLE JOINTS BONES

Numbness

Joint pain

Muscle weakness

Joint swelling

EARS

Ringing in ears

Loss of hearing

EYES

Pain

Redness

Loss of vision

Double or blurred vision

Dryness

SKIN

Redness

Rash

Nodules bumps

Hair loss

Color changes of hands or feet

THROAT

Frequent sore throats

Hoarseness

Difficulty in swallowing

Pain in jaw

HEART AND LUNGS

Chest pain

Palpitations

Shortness of breath

Fainting

Swollen legs or feet

Cough

Blood

Anemia

Clots

KIDNEY / URINE / BLADDER

Frequent or painful urination

blood in urine

Leakage of urine

Woman Only:

Abnormal Pap smear

Irregular periods

Bleeding between periods

PMS

Pelvic pain

Vaginal discharge

Do you smoke?(Required)

Currently

Past

Never

packs/day

for many years

Quit Date

MM slash DD slash YYYY

If you do smoke, are you interested in quitting?

Yes

No

Other nicotine use

Yes

No

Exposure to second hand smoke?

Yes

No

Do you drink alcohol?

Beer

Wine

Liquor

No

How many drinks per week?

How many caffeinated beverages per day?

Beverages

Coffee

Tea

Sodas

Energy Supplements

Recreational drug use?

Yes

No

Do you exercise regularly?

Yes

No

how many times per week?

Type of exercise:

Do you feel safe in your home?

Yes

No

How many hours of sleep do you get per night?

Do you wake feeling well rested?

Yes

No

Desired Weight (in Pound)

Email(Required)

Δ

Weight Loss New Patient Form

Clearwater

Phone: 727-477-3636
Email: Info@clearwateraesthetics.com
Office Address: 818 Chestnut St, Clearwater, FL 33756

Office timings

Wednesday to Sunday : 11am to 5pm
Monday - Tuesday : Closed

COPYRIGHT © 2025 CLEAR WATER AESTHETICS. ALL RIGHTS RESERVED

Sign up

Click on Sign Up button to create a new account.

Sign up

Login to your account

Forgot your password?

Sign in

Click on Sign in button to login to the site.

Sign in

Create Account

Sign In

If you have a personal account, please sign in

Sign in

Forgot Password

Lost your password? Please enter your username or email address. You will receive a link to create a new password via email.