Patient Name: Date of Birth: _ Medical Record Number: Mailing Address: PO Box 29086 Thornton, CO 80229 Phone: 720.215.0700 Fax: 877.332.3131 Allergies Do you have Allergies Yes No If yes, please complete specifics below To latex? Yes No To iodine? Yes No To seafood/shellfish? Yes No To what medications? To what foods? Do you have a Special Diet? No Yes (please specify) Medications Do you taking pain medication? Yes No If yes, please list all or attach a separate list Pain Medication Dose Times per day Reason for taking the medication All Other Medications, Dose Times per day Reason for taking the medication Vitamins, Supplements Pharmacy _ Phone # Address:
Past Medical/Family History Patient Father Mother Brother No Medical Problems Allergies Anemia Anxiety Arthritis Asthma Back Pain Bleeding Disorder Clotting Disorder Blood Transfusion Cancer Cardiovascular Disease Congestive Heart Failure COPD Depression Diabetes Type 1 Diabetes Type 2 GERD Gastrointestinal Disorder Glaucoma GYN Problems Headaches Heart Attack Heart Murmur Hepatitis HIV Hypertension Insomnia Kidney Disease Lipid Disorder Musculoskeletal Osteoporosis Positive PPD Rheumatoid Arthritis Seizures Stroke Substance Abuse Thyroid Disorder Tuberculosis Other (please list below) Please list any other medical condition not listed above (please also specify who has that condition).
Past Surgical History No surgeries Appendectomy Gall Bladder Tonsillectomy CABG/cardiac bypass Heart surgery Lung surgery Hernia What type? Thyroid surgery Mastectomy Hysterectomy Neck surgery Spine surgery Hip surgery Knee surgery Foot surgery Shoulder surgery Elbow surgery Wrist surgery Hand surgery Other Have you had any other surgeries for the current problem? Yes No Please specify Where? Surgeon: Year:
Social History Tobacco/Nicotine Do you use tobacco/nicotine Yes No Cigarettes Pipe Cigars Snuff Chew Other I currently smoke I smoke packs per day and have for years I used to smoke I smoked packs per day for years and quit_ I have never smoked Alcohol Use Do you drink alcohol Yes No Beer Wine Cocktails Liquor I currently drink drinks per day week month year I used to drink I stopped (date or year) I have never used alcohol Drug/Controlled Substance/Illegal Substance Use Have you ever used Yes No I currently use I have never used drugs/controlled substances/illegal substances I used to use I stopped (date or year) I currently use daily weekly monthly a few times per year Substances ever used Marijuana Hallucinogens Benzodiazepines Anabolic Steroids Opioids: Oral/pills Inhaled/intranasal IV Smoked Cocaine: Oral/pills Inhaled/intranasal IV Smoked Amphetamines: Oral/pills Inhaled/intranasal IV Smoked Meth: Oral/pills Inhaled/intranasal IV Smoked Other:
Please check the Yes or No box for each condition and add comments as appropriate. Review of Systems General/Constitutional Weight gain Yes No Weight loss Yes No Fatigue Yes No Insomnia Yes No Fever Yes No Night-sweats/chills Yes No Eye/Head Glasses/contacts Yes No Cataracts Yes No Glaucoma Yes No Difficulty with vision Yes No Ear/Nose/Mouth/Throat Sinus trouble Yes No Hearing loss Yes No Ringing in ears Yes No Sore Throat Yes No Heart/Cardiovascular Irregular heartbeat Yes No High blood pressure Yes No Chest pain Yes No Fluttering in chest Yes No Coronary disease Yes No Respiratory/Lung Shortness of breath Yes No Difficulty breathing Yes No Lung disease Yes No Persistent cough Yes No Gastrointestinal Decreased appetite Yes No Heartburn Yes No Nausea Yes No Vomiting Yes No Diarrhea Yes No Constipation Yes No Hepatitis A, B, C Yes No Muscle/Bones Arthritis Yes No Fractures Yes No Sprains Yes No Genitourinary/Kidneys Kidney stone Yes No Urinary infection Yes No Difficulty urinating Yes No Painful urination Yes No Prostate problems Yes No Skin Masses Yes No
Blisters Yes No Rashes/Dermatitis Yes No Non-healing wounds Yes No Neurologic Seizures Yes No Numbness Yes No Tingling Yes No Severe headaches Yes No Mental Health Anxiety Yes No Depression Yes No Other (please describe) Yes No Endocrine Increased thirst Yes No Diabetes Yes No How many year? What medication do you take? Thyroid Yes No Blood/Lymph Bleeding or clotting Yes No problems Anemia Yes No Swollen or enlarged lymph Yes No nodes Immunological Hay fever Yes No Lupus Yes No Rheumatoid disease Yes No Autoimmune disease Yes No Connective tissue disease Yes No HIV/AIDS Yes No Is there anything else that you think we should know about your health, medical history, or medical condition?_ I understand that any person who knowingly and with intent to defraud any insurance company or other persons, files a statement or claim containing any materially false information or who conceals, for the purpose of misleading, information concerning any fact, commits a fraudulent act, which is a crime subject to criminal prosecution and civil penalties. _ Signature of patient, parent, or guardian (if patient is a minor) _ Date ----------------------------------------------------For Office Use --------------------------------------------------------- I have reviewed the Medical History Questionnaire, which encompasses the patient s past medical history, past surgical history, social history, family history, and a comprehensive 14 point review of systems. I have discussed the patient responses with the patient during the consultation. _ Provider signature _ Date