Follow up Check in for IN OFFICE appointment

Please complete the following check in for your upcoming in office visit with your Provider

In office visit:

First Name Last Name*
First Last
Best Phone*
Email*
Main Concerns you would like to discuss at your Video Visit*
Report your most recent Weight (pounds)
NEW Drug Allergies*
NEW ALLERGIES ONLY You can answer NO or YES and list your new allergies
NEW Hospitalizations/Surgeries/Procedures (Please include exact dates & Locations)*
NEW CHANGES ONLY Example: 01/31/2002-Thyroidectomy
Please list current problems/Symptoms you are experiencing now in past 1 month*
Example: Fatigue, Lump in neck, can’t sleep, constipation
Please List all medications name, Dose and how you are taking the medication.*
example: Synthroid 100 mcg 1 daily OR You may copy and paste a medication list. Please try your best to list dose and directions of your medications
Are you currently using diabetes technology?*
- I am on a Blood Glucose Meter
- I am on an Insulin Pump
- I am on a CGMS (Continuous Glucose Monitoring System)
- I do not have ANY devices
- I am NOT DIABETIC
List your Diabetes Device(s) Name
My Diabetes Device(s) are linked to the office
- Yes
- No
- I don’t know
- I will email my Blood sugars to info@denverendocenter.com