9399 Crown Crest Blvd, Suite 200 Sierra Medical Office Building Parker, CO 80138 Phone: (303) 269-4410 Fax: (303) 269-4411 www.timberviewclinic.com Jeffrey Turk, MD Paige Turk, MD Shauna Gulley, MD Jeremy Armstrong, PA-C PATIENT INFORMATION Patient Name: ______________________________________ Birth Date: ______________ Age: _____ Date: __________ Other physicians Specialty Phone number (if available) ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Current Medications (write additional on back of page) Name of Medication: Dose: Frequency: Prescribed By: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Preferred Pharmacy Name: ______________________________ Preferred Pharmacy Phone #: _______________________ Medication Allergy: Type of Reaction: _______________________________________________ _______________________________________________ Medication Allergy: Type of Reaction: __________________________________________________ __________________________________________________ PATIENT HISTORY Past Medical History: Headache ______________________ COPD/Emphysema________________ CAD/MI/Heart failure _____________ Asthma ________________________ Allergies _______________________ Sinusitis ________________________ Pneumonia _____________________ Osteoporosis/osteopenia __________ Stroke _________________________ Gallbladder disease _______________ Bowel irregularity ________________ Ear infections ____________________ Incontinence ____________________ Sexual dysfunction _______________ Hepatitis _______________________ Anemia ________________________ Arthritis/gout ___________________ GERD __________________________ Depression/anxiety _______________ Thyroid disorder _________________ Diverticulitis ____________________ Rheumatologic disease ____________ Other infectious diseases __________ Breast abnormality _______________ Cancer (type) ___________________ High blood pressure ______________ High cholesterol _________________ Glaucoma ______________________ Kidney disease ___________________ Insomnia _______________________ Obstructive sleep apnea ___________ Eczema ________________________ RSV____________________________ Diabetes________________________ Other__________________________ Past Surgical History / Hospitalizations: (Please list past surgeries/hospitalizations and approximate date) __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ (continue to next page) Patient Name: _______________________________________ Birth Date: ______________ Preventative Screening: (please indicate last date) Female: Last menstrual period ________________________ Mammogram ______________________________ Pap smear ________________________________ Male: Last prostate exam _________________________ Female and Male: Colonoscopy _________________________________ Bone density _______________________________ Tetanus/Pertussis vaccine ______________________ Pneumonia vaccine ___________________________ Shingles vaccine ______________________________ Are your vaccines up to date as far as you know? Yes No No idea Past Family History: Heart disease High blood pressure Stroke Cancer – type Glaucoma Diabetes Epilepsy/convulsions Bleeding disorder Kidney disease Thyroid disease Mental illness Osteoporosis Other Mother Father Grandparent Sibling Children ___________ _____________ _______________ ________________________ ___________ _____________ _______________ ________________________ Social History: Is your diet: Well Balanced Diabetic Excessive Fat/Calories Vegetarian/vegan Gluten free Other Exercise: Do you exercise? YesNo How often do you exercise? ___________________________ What activities? _____________________________________________________________________ Marital Status: Married Single Divorced Widowed Live with: Alone Children Parent(s) Spouse/Partner Other Education: Highest level of education completed ___________________________ Occupation: ______________________________ Sexual activity: Not Active Active Men Women Both # Lifetime Sexual Partners ______ # Current Sexual Partners ______ Safety: Currently feel safe at home Physical Abuse Sexual Abuse Emotional Abuse Other Tobacco use: No Tobacco Use Cigarettes Pipe/Cigar Chew Secondhand Exposure Other Packs smoked/day? _________ Total years smoked? ________________ If quit, when? __________ Have you considered tobacco cessation? YesNo Alcohol use: Do you drink? Yes No # per week: _______________________________ Have you ever been an alcoholic or problem drinker? Yes No Recreational drug use: None Drug use details: Route __________ Cocaine Current Use Narcotics Heroin Prescription drug Previous Use Designer/Club Inhalants Marijuana Opiates Amphetamines Hallucinogens Signature of Reviewing Physician ___________________________________ Date _____________________
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