Vero Beach Primary Care

Telehealth Medical Assessment

Please complete the information below so Vero Beach Primary Care can review your request and determine whether a consultation may be appropriate.

This form is not for medical emergencies. If you are experiencing a medical emergency, call 911 or seek immediate emergency medical care. Submission of this form does not establish a provider-patient relationship and does not guarantee that treatment will be prescribed.

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Full Address *

Reason for Visit

Primary reason for visit *

What concerns would you like to discuss?

Weight changes or difficulty managing weight Fatigue or changes in energy levels Sleep-related concerns Mood or concentration changes Sexual health or libido concerns Menstrual changes, menopause, perimenopause, or PCOS history Questions about lab work or hormone levels

Health Information

Height *

Weight *

Do you have any known medical conditions? *

Current prescription medications *

Over-the-counter medications, supplements, vitamins, or herbal products *

Allergies *

Have you previously tried any approaches for weight management, hormone concerns, or the reason for today’s visit?

Are you currently pregnant, trying to become pregnant, or breastfeeding?

Additional information for the provider

Acknowledgment

I understand this form is for assessment request purposes only and does not guarantee that treatment, medication, or telehealth services will be appropriate.

✓

Thank You

Your request has been received.

Vero Beach Primary Care will review the information provided and contact you to coordinate scheduling your telehealth evaluation, and schedule labs, if appropriate.

This form does not establish a provider-patient relationship and does not guarantee that telehealth services, treatment, or prescription medication will be appropriate.

Telehealth Medical Assessment

Thank You

Hours

Vero Beach Primary Care