Preventative Wellness Survey

Please complete and submit this survey and one of our qualified patient coordinators will contact you within 24 hours to schedule your appointment.

Name (required):

Phone (required):

Required Fields

*This form verifies you have valid insurance.

Insurance Carrier (required):

Member ID (required):

Family Member/Friend #1 Name:

Family Member/Friend #1 ID:

Family Member/Friend #2 Name:

Family Member/Friend #2 ID:

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

Notes (optional)

Affiliation (required)

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QUESTIONS? CALL US AT 866.991.3804
Fountain of Youth M.D.
200 Galleria Parkway, Atlanta, GA 30339
www.FountainMD.com

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