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
"Eurycoma longifolia information from NPGS/GRIN". www.ars-grin.gov. http://www.ars-grin.gov/cgi-bin/npgs/html/taxon.pl?417514. Retrieved 2008-03-14. Chan, Kit-Lam; Low, Bin-Seng; Teh, Chin-Hoe; Das, Prashanta K, "The effect of Eurycoma longifolia on sperm quality of male rats," Nat Prod Commun, 2009 Oct, 4(10):1331-6 Mohd Ridzuan, M A R; Sow, A; Noor Rain, A; Mohd Ilham, A; Z
Kimberly S. Beasley, soprano Jacksonville, FL 32207 Performing Experience Upcoming Engagements: Jacksonville University Orchestra and Chorus Messiah Soloist, December 2011 Jacksonville Symphony Orchestra, New Year’s Eve Gala, December 31, 2011 Jacksonville University Faculty Recital, February 2012 Valparaiso University, Guest performance, April 2012 Jacksonville Symphony O
