Patient Form

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Patient Name
Date of Birth
Mailing Address
Emergency Contact's Name

Please list any Conditions/Disease below as well as medications used for treatment.

No Condition/Disease
No Other Medications/Supplements
Have you ever had any of the following conditions (check ALL that apply):

Please rate each of the following from 1 star - 10 stars (1 being the worst/bad and 10 being the highest/excellent)

Answer the following

What best describes your activity level:

System Review: Please rate each symptom based upon your experiences over the last 60 days. 1 = No Symptoms 2 star = Mild Symptoms 3 star = Moderate Symptoms 4 star = Severe Symptoms.

HEAD

EENT

EARS

HEART

MUSCULOSKELETAL

NEUROENDOCRINE

SKIN DISORDERS

MENTAL/EMOTIONAL

WEIGHT

GI

GU

I PATIENT NAME, have read and fully completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I authorize the healthcare provider, nurse, medical assistants, and any other deemed medical staff to administer treatments and medications as they deem necessary and advisable including recommending/ordering laboratory and other diagnostic tests as indicated for my medical concerns. I understand that by identifying my health risk factors, Medfit of Georgia will then recommend targeted lifestyle support that, if acted upon, can help me reduce my risk of disease and increase my ability to be healthier.I understand I have the right to refuse and treatment recommendation. I understand your office does not replace my primary care provider.

While all treatments are recommended to achieve the best possible results, I do understand that not all treatments will have the same results on every client, therefore no guarantee can be given. I also understand that any recommendations made are up to me to choose to accept and engage in for optimal results to occur.
I understand that if I withhold information or provide misinformation, incomplete results or recommendations can occur from treatments received. I am aware that it is my responsibility to inform you of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Medfit of Georgia from liability and assume full responsibility thereof.

Acknowledgement
Clear Signature
Date
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