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Weight Loss New Patient

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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)

MM slash DD slash YYYY
Gender(Required)
Translator Needed

Do you have any ALLERGIES?

Drug Allergies(Required)
Food Allergies(Required)
Environmental Allergies(Required)
Are you in good health at the present time of the best of your knowledge ?(Required)
Are you under a doctor's care at the present time ?(Required)
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:
Surgery / Procedures History:(check all that apply)

SYSTEMS REVIEWS

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

GENERAL
NERVOUS SYSTEM
STOMACH AND INTESTINES
PSYCHIATRIC
MUSCLE JOINTS BONES
EARS
EYES
SKIN
THROAT
HEART AND LUNGS
Blood
KIDNEY / URINE / BLADDER
Woman Only:
Do you smoke?(Required)
MM slash DD slash YYYY
If you do smoke, are you interested in quitting?
Other nicotine use
Exposure to second hand smoke?
Do you drink alcohol?
Beverages
Recreational drug use?
Do you exercise regularly?
Do you feel safe in your home?
Do you wake feeling well rested?

Clearwater Primary Care & Aesthetics
Clearwater Primary Care & Aesthetics
66 Google reviews

Get In Touch

  • Phone: (727) 386-6449
  • Email: Info@clearwateraesthetics.com
  • Office Address: 818 Chestnut St, Clearwater, FL 33756

Other Location

  • @ Onyxx Wellness
  • Office Address: 1000 Lakeview # Suite 2 Clearwater Fl, 33756

Other Location

  • Faces By Monica & Amalyn
  • Office Address: 6262 Bird Rd #3d, Miami, FL 33155, United States

Other Location

  • Ageless Health & Aesthetics
  • Office Address: 4104 Milenial Blvd. Ste. 111 Orlando Florida 32839

COPYRIGHT © 2023 CLEAR WATER AESTHETICS. ALL RIGHTS RESERVED

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