Fountain of Youth Medical Spa Allergy - Verification Survey

Allergy Verification Survey

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

*Required fields

Name (required)

Phone (required)

Your Email (required)

Insurance Carrier (required)

Date of Birth: MM-DD-YYYY (required)

Member ID (required)


RxBin# (required):

RxGroup (required):

Family Member 1 Name:

Family Member 1 ID:

Date of Birth: MM-DD-YYYY

Family Member 2 Name:

Family Member 2 ID:

Date of Birth: MM-DD-YYYY

Have you experience 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 I Type II N/A

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)

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