PARTNERS IN ENDOCRINOLOGY
DR. JYOTHI MAMIDI JUAREZ
Who referred you? blanks Reason for visit? blank Please Select Type 2 diabetes Type 1 Diabetes Hypothyroid Hyperthyroid Thyroid nodules Fatigue Weight gain Adrenal Pituitary Osteoporosis Other
Please send a copy of your ID and insurance card (front and back) via secure text.
Please indicate primary insurance
MEDICAL HISTORY
How much exercise per week (hours/week) ? blanks Type of exercise? blank
Do you drink alcohol? blanksIf so, how much and how often: blank
Illegal drugs? No Yes Type? blanks
Answer the following questions ONLY IF YOU HAVE DIABETES.
Last eye exam?blanks Last flu vaccine? blank
Last Pneumonia vaccine?blanks Covid vaccine? blank
What type of meter/ test strips do you use? blanksHow many times a day do you check your sugar? blank
Are you on an insulin pump/ if so which brand: blanks Are you using a continuous glucose monitor like Freestyle Libre or Dexcom? (if so, which one? blank
Review of Systems
Place a check in any box, if you are having the following symptoms: