Medical History Form

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Medical History Form

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Denver Endocrinology, Diabetes and Thyroid Center, PC
Medical History Form

Prior to your first appointment, new patients need to fill out the below form, either online or on paper.

Medical History

Patient Name*
First Last
Email*
Phone*
Today's Date*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Occupation*
Primary Care Provider and Phone #*
Referring Physician (if not PCP) & Phone Number
Other Care Providers & Phone #
Main Concern(s)/Reason for visit today*
ALLERGIES (Please include type of reaction to each allergy listed)*
MEDICATIONS (Both prescription and over-the-counter including herbal, vitamins, etc)*
Name of medication and dosage
HOSPITALIZATIONS/SURGERIES/PROCEDURES*
(Please include exact date or at least year)
FAMILY HISTORY*
(List any health problems of your mother, father, siblings, children, or grandparents only)
Current Smoker*
- Yes
- No
Number of cigarettes per day
Please enter a number greater than or equal to 1.
Previous smoker*
- Yes
- No
Date quit:
MM slash DD slash YYYY
Alcohol use*
- Yes
- No
Number of drinks per day
Exercise*
Please indicate whether you perform regular exercise, the duration, type, and number of days in a week it is done.
PERSONAL HISTORY*
Please list previous health problems
Review of System*
Check current problems/symptoms you are experiencing now in the past 1 month
- Weight gain
- Weight loss
- Fatigue
- Easy bruising
- Difficulty breathing
- Breast Pain
- Breast Discharge
- Breast Enlargement
- Pain in feet
- Fractures
- Muscle aches
- Change in hand size
- Excessive urination
- Heat intolerance
- Hot flashes
- Flushing
- Excessive sweating
- Brittle nails
- Rash
- Change in skin color
- Dry skin
- Stretch marks
- Darkening of skin
- Peripheral vision loss
- Worsening vision
- Blurred vision
- Bulging eyes
- Headache
- Double vision
- Hoarseness
- Snoring
- Inability to smell
- Change in dental bite
- Change in head size
- Neck pain (front)
- Swollen glands
- Neck lump
- Neck swelling
- Chest pain/discomfort
- Leg pain with exercise
- Palpitations
- Abdominal pain
- Constipation
- Diarrhea
- Diarrhea with milk
- Difficulty swallowing
- Nausea
- Vomiting
- Pain with swallowing
- Impotence
- Abnormal periods
- Pain with intercourse
- Pain with urination
- Kidney stones
- Bone pain
- Back pain
- Joint pain
- Muscle cramps
- Muscle weakness
- Pain in hands
- Change in foot size
- Dizziness
- Fainting
- Weakness
- Lightheadedness
- Dizziness with standing
- Change in concentration
- Change in memory
- Frequent falls
- Emotional swings
- Numbness in hands/feet
- Burning in hands/feet
- Anxiety
- Depression
- Difficulty sleeping
- Acne
- Decrease in appetite
- Increase in appetite
- Feeling full before done eating
- Cold intolerance
- Excessive thirst
- Excess face/body hair
- Loss of hair
- Decrease in height
- Decrease in sex drive
- Other (Please Describe Below)
Please describe your OTHER problem/symptoms
Use this space to indicate any current problems/symptoms you have that was not covered in the list above.
Height (ft' In")*
Weight (pounds)*
Local Pharmacy
Mail Order Pharmacy

Patient Privacy Policy

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DENVER ENDOCRINOLOGY, DIABETES & THYROID CENTER

Providing specialized care in the areas of diabetes, thyroid disease, osteoporosis and bone disorders, cholesterol management, adrenal gland disorders, pituitary disorders, polycystic ovary syndrome (PCOS), and male testicular dysfunction.

Quick Links

New Patients
Follow My Health
Portal Instructions
Schedule Appointment
Prescription Refills
Pay a Bill

Location

Denver Endocrinology, Diabetes and Thyroid Center
799 E. Hampden Ave. Suite 525
Englewood, CO 80113

Contact Us

P: (303) 321-2644
F: (303) 321-2446
E: info@denverendocenter.com

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