Physical Address (No PO Box Numbers):______

Nicole Pinkerton, MD

575 Rivergate Lane, Suite 207

Durango, CO 81301

Name:______Date:______

SSN:______DOB:______

Physical Address (No PO Box Numbers):______

Mailing Address (if different): ______

Preferred contact phone number and type:______

Email address:______

Marital Status:______Employer:______Occupation:______

Race/Ethnicity:______Preferred Language:______

Current Pharmacy:______

Who should we contact in case of Emergency: ______Phone: ______

Primary Care Provider or Referring physician, if any:______

REASON FOR VISIT TODAY:______

Do you currently experience any problems in the following areas, please circle all that apply

General: fevers, chills, sweats, anorexia, fatigue, sleep problems, weight gain or weight loss

Eyes: eye pain, vision loss, excessive tears, blurring, irritation, redness, discharge

Ears/Nose/Throat: ear pain, decreased hearing, nasal obstruction or discharge, sore throat

Heart: chest pain, palpitations, rapid heart rate, slow heart rate, leg pain, swelling in legs

Lungs: cough, wheezing, shortness of breath, excessive sputum, bloody sputum

GI: nausea, vomiting, diarrhea, constipation, heartburn, abdominal pain

GU: urinary problems, vaginal discharge or sores, pelvic pain, changes in menstrual bleeding

MS: back pain, limb pain, joint pain, swelling or stiffness, muscle cramps, muscle weakness

Skin: rash, itching, dryness, ulcers or growths, worrisome lesions, breast problems

Neuro: headache, weakness, numbness, seizures, fainting, tremors, confusion

Psych: depression, anxiety, memory loss, mental changes, paranoia

Endocrine: cold or heat intolerance, hot flashes, weight changes, frequent drinking or voiding

Heme: abnormal bruising, abnormal bleeding, enlarged lymph nodes

Imm: hives, hay fever, persistent infection, HIV exposure

Health Screening:

Last Pap and result: ______

Last mammogram and result: ______

Last colonscopy and result: ______

Last bone density and result: ______

Number of pregnancies: ______

Number and type of births: ______

Age when your started having menstrual cycles: ______

Age when you stopped having menstrual cycles/menopause: ______

Are you sexually active: ______

Contraception used: ______

Any history of abnormal pap tests (if yes, when and what treatment): ______

______

Any history of STDs (if yes, when and what type): ______

Have you had more than 5 sexual partners in your lifetime: ______

Do you routinely check your breasts: ______

Menstual History, if applicable

Last normal menstrual period ______

Number of days between periods? (1st day to 1st day) ______

Number of bleeding days? ______

Any bleeding between periods? ______

Do you have pain or cramping with your periods? ______

Periods are regular/irregular? ______

How many periods in the last year? ______

NAME______

Past Medical History, please check all that apply Family History, please check all that apply

£ High Blood Pressure and list affected relative.

£ Heart Disease

£ Other Heart condition

£ High cholesterol

£ Diabetes

£ Stroke

£ Thyroid Disease

£ Osteoporosis

£ Gastrointestinal disease

£ Kidney infection/stones

£ Seizure disorder

£ Blood clot/Thrombosis

£ Blood disorder

£ Asthma

£ Other respiratory disease

£ Anxiety

£ Depression

£ Blood transfusion

£ Cancer (type)______

£ Other

£ High blood pressure

£ Heart Disease

£ Other Heart condition

£ Diabetes

£ Stroke

£ Bleeding disorder

£ Thyroid disease

£ Cancer

£ Other

Surgical History, please list procedure and date

______

Social History, please check all that apply

£ I have never smoked

£ I stopped smoking Quit Date______

£ I currently smoke Number of packs/day______

£ I do not drink alcohol

£ I drink alcohol How many days/week______

On a typical day, How many drinks/day______

£ I do not use any recreational drugs

£ I use recreational drugs Which one(s)?______

Medication and supplements, please list drug, amount and how taken

______

Allergies, please list any medication allergies and reaction

______

How did you hear about us (please check all that apply)

£ Referred by a doctor. ______

£ Recommended by a friend

Who should we thank ______

£ Newspaper advertisement

£ Radio advertisement

£ Insurance company listing

£ Phone book

£ Other: ______

NAME OF PATIENT: / DOB:

Communications Preferences

From time to time, it may be necessary and/or desirable to contact you regarding your care. Please complete the following to indicate your preferences for communicating with you.

I wish to be contacted in the following manner:

(only complete the options that apply to you)

Home Phone: ______May we leave a detailed message? Yes No

Cell Phone: ______May we leave a detailed message? Yes No

Work Phone: ______May we call you at work? Yes No

May we leave a detailed message? Yes No

Other Phone (please specify): ______May we leave a detailed message? Yes No

Other (please be specific):______

May we speak with someone else regarding your medical care, such as your primary care provider or a family member? Yes No

If so, please list their name and their relationship to you.

Name: ______Relationship: ______

Currently, we will contact you by phone to remind you of upcoming appointments. Additionally, we will send health maintenance reminders by mail and you will be notified of your test results by phone or by mail, depending on the nature of your tests. If you choose to be contacted by another method or no notification at all, please use this area to let us know your preferences.

______

I understand that this request is only applicable to information held by Specialists in Women’s Care, PC. I also understand that the use of an alternative means of communication may not be protected and could endanger my privacy. I understand that I may change this consent, in writing, at any time. By signing this form, I am consenting to the use and disclosure of my protected health information by Specialists in Women’s Care, PC.

______

Signature of patient, parent or legal guardian Date