Have you experienced any of the following in the past year?
1. Itchy, stuffy, and/or running eyes and/or nose? Yes No
2. Abdominal Pain, diarrhea, nausea or vomiting? Yes No
3. Sore throat or difficulty breathing? Yes No
4. Weight Gain or difficulty with weight loss? Yes No
5. Skin rashes, hives, eczema, itching or swelling? Yes No
6. Do you currently take allergy meds (prescription or OTC)? Yes No
7. Have you ever had your cholesterol checked? Yes No
8. When was the last time?
9. Are you Diabetic? If so select Type: Type l Type ll
10. Are you interested in weight loss? If so, what is your desired goal:
11. Are you currently taking Beta Blockers? Yes No
12. Are you currently taking Anti-Depressants? Yes No
13. Are you currently taking Zyrtec, Clariton, etc.? Yes No
QUESTIONS? CALL US AT 866.991.3804
Fountain of Youth M.D.
200 Galleria Parkway, Atlanta, GA 30339