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4790 Table Mesa Drive, Ste 202
Phone: (303) 444-0840
Boulder, CO 80305
Fax: (303) 444-0838
www.choicespc.net
PATIENT MEDICAL INFORMATION SHEET
Name: ____________________________________________Age:_______

Who referred you to this office?
__________________________________
phone number:
________________________________________________
Who is your primary care physician
(PCP)
________________________________________________________
Your pharmacy _____________________________Phone # ___________
Why are you seeing the doctor today
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Do you have Allergies to Drugs: (CIRCLE) None Penicillin Sulfa IVP Dye
(please list)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Do you have other Allergies to: (CIRCLE and list ) Latex other items:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Current Medications with doses frequency: None (Circle all that apply
and list others)
Allopurinol, Amitryptriline, Aspirin, Cardura 2 4 8 mg 1/2tab, Casodex
Coumadin, DDAVP, Detrol, Detrol LA, Ditropan, Ditropan XL, Elmiron,
Flomax, HCTZ, Hytrin 2 5 10 mg, Imipramine, Lupron, Lyrica, Neurontin,
Nitroglycerin, Nitrates, Percocet, Plavix, Proscar, Viagra, Vicodin, Zoladex
(other medications)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
List All Herbs and Supplements that you take with doses and
frequency?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Location (Identify specific location of the pain or problem)
_____________________________________________________________
_____________________________________________________________
Quality (Has the pain increased or decreased since the injury or symptom
happened)
_____________________________________________________________
_____________________________________________________________
Severity (Identify on a scale of 1 to 10 the degree of pain)
None - 1 2 3 4 5 6 7 8 9 10 - Severe
Duration (Identify the length of time of the injury or symptom)
_____________________________________________________________
____________________________________________________________
Timing (Is there a time or condition that increases or decreases the pain)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Context (How did the injury happen or when did the symptoms start)
_____________________________________________________________
_____________________________________________________________
Modifying Factors (Do certain conditions increase or decrease the pain or
problem)
_____________________________________________________________
_____________________________________________________________
Associated Signs & Symptoms (Has this injury or symptom created
problems with other areas of the body)
List All Operations/ Surgeries: (Circle and include date)
None
Appendix, Back/Neck Surgery, Bladder Repair, Gallbladder, Hernia, Heart
Bypass, Heart Stents, Kidney Removal, Radical Prostatectomy, Ureteral
Stone, TURP, Uterus (ovaries tubes), TUR Bladder Tumor, Vasectomy,
Others Operations
Surgeries:_____________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
List All of Your Medical Conditions & onset date:
None
High Blood Pressure, Diabetes, Heart Attack, Stroke, Heart Murmur,
Congestive Heart Failure, Other Heart Problems, Asthma, COPD,
Emphysema, Pneumonia, HIV(AIDS), Impotence, Kidney Stones or
Infection, Rheumatic Fever, Thyroid Trouble, Tuberculosis, Ulcer, Seizures,
Head Injury.
Cancer of: Prostate Kidney Testis
Others:_______________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Any of These Run in Your Family? (Please circle and follow with
relationship to you.)
High Blood Pressure, Diabetes, Kidney Stones, Stroke, Bleeding, Heart
Disease, Problems with anesthesia
Prostate Cancer Other cancers (type)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Do you smoke? No If you ever smoked, when did you
quit?_________________________________________________________
____
Yes How many packs per day? ½ 1 2 3 For how many
years?________________________________________________________
_____
Do you drink alcohol? No Yes How
much?________________________________________________________
_____
Do you drink caffeinated beverages? No Yes How much?
_____________________________________________________________
Have you had Blood transfusions? Yes No When?
_____________________________________________________________

Are you:
Married Single Divorced Widowed
Do you have Children? No Yes
How many ____________________________________________________
What is Your Occupation?
_____________________________________________________________

Year of last physical
Where?
_____________________________________________________________
When did you have your last: chest X-ray, Electrocardiogram, Pap Smear,
Colonoscopy.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
For Women only:

Are you Pregnant?
Yes No
Number of pregnancies
Age of first pregnancy

Age of first
menses?______________________________________________________
_______
Last menstrual period
_____________________________________________________________
Duration of periods and
quality_______________________________________________________
Hormone replacement
Yes No Type and dosage
_____________________________________________________________
_____________________________________________________________
Birth control
Yes No Type and dosage
_____________________________________________________________


PLEASE CIRCLE IF YOU CURRENTLY HAVE ANY OF THESE
SYMPTOMS:

General/Constitutional: Fever, Weight Loss, Chills
Eyes, Ears, Nose, Throat: Blurry Vision, Cataracts, Hearing Loss
Cardiovascular/Respiratory: Chest Pains, Swollen Ankles, Shortness of
Breath
Genitourinary: Incontinence, Painful Urination, Blood in Urine
Musculoskeletal/Neurologic: Chronic Back Pain, Chronic Neck Pain,
Numbness
Integumentary/Skin: Rash, Persistent Itching Skin, Cancer History
Hematologic/Lymphatic: Swollen Glands, Abnormal Bleeding,
Transfusion History

Source: http://choicespc.net/wp-content/uploads/2013/04/New-Patient-Hedical-History.pdf

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