Follow up Questionnaire for Dr Deaver - Denver Endocrinology, Diabetes and Thyroid Center, PC

Please update your provider on your health conditions and medications by completing the Follow up Medical Check-in below, otherwise a Medical Assistant will call you to check you in
Once you complete your Phreesia check in, you will automatically be put in queue to receive a link for ZOOM. 15-20 minutes prior to your virtual visit, you will receive a link from Phreesia to verify your identity, then you will receive your ZOOM link. Once you enter the virtual room via your ZOOM link, you will be in a waiting room for you provider. DO NOT EXIT your ZOOM waiting room, otherwise you will not be able to re-enter the ZOOM waiting room.
If you do not wish to do this please contact the office for an alternative option for your Video Visit at (303) 321 2644 x 1
IF you are a diabetic, it is strongly advise that you email or upload your blood sugars before seeing the provider. This will prevent your appointment from being reschedule. (info@denverendocenter.com)

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
Last Labs COMPLETED: (Please include exact dates & Lab location)*
Labs done 7/20/2020 with Labcorp; Labs done 5/2/2020 @ Dr Tom Smith’s office
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
Dr Deaver will text you a link to connect with her for a video visit. This text msg will be sent out to you around your appointment time.