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Schedule Today: Now offering telemedicine appointments throughout Florida

In-Person Appointments Available in Jacksonville Beach, Tallahassee, The Villages, Winter Haven

PATIENT PORTAL

HEALTH HISTORY QUESTIONNAIRE

Please complete the following forms to allow us to schedule your assessment

HEALTH HISTORY QUESTIONNAIRE

Name(Required)
MM slash DD slash YYYY
Address
Do you have a history of Type 1 DM?
Do you have a history of Diabetic Ketoacidosis?
Do you have a history of Diabetic Retinopathy?
To the best of your knowledge, are you allergic to semaglutide or another GLP-1 receptor agonist?
Are you currently pregnant or breastfeeding?
Do you have a personal or family history of medullary thyroid carcinoma?
Do you have a history of multiple endocrine neoplasia syndrome?
Do you have a history of pancreatitis?
Do you drink alcohol?
Do you have a history of end stage renal disease (on dialysis) or known issues with your kidneys?
This field is for validation purposes and should be left unchanged.

Contact new horizon weight loss clinics

850-906-5001
info@newhorizonclinics.com
2633-A Mahan Drive
Tallahassee, FL 32308