Alpine Family Practice
1400 S. Potomac Suite 130
Aurora Co 80012
Phone: (303) 752-1157 Fax: (303) 752-1236
            This is a confidential record of your medical history and will be kept in your chart.

Patient History Information

Have you ever had or suffer from any of the following:

Others not mentioned:

Hospitalizations:

Surgeries (Type & Date):

                                                                           Social History   

Marital Status:  Single   Married   Divorced  Widowed                  Number of children:
Occupation:
Do you smoke cigarettes? Yes     No     How many packs per day? How long have you smoked?
Have you ever smoked in the past? Yes     No      If yes, for how long?
Do you chew tobacco or snuff? Yes No   How long have you used oral tobacco?
Do you drink alcoholic beverages? Yes No     Type:  Beer  Wine  Liquor  Mixed Drinks
How many drinks per day do you have? How many years have you drank alcohol?
How many caffeinated drinks do you have per day?
Do you have any pets? Yes No     If yes what kind?
To what countries have you traveled out side of the United States?

Birth History
Children under 18 years old

Did mother take prenatal vitamins? Yes   No                  Birth weight
Number days spent in the hospital?             Term  Preterm  Post term
Type of delivery? Vaginal  C-section  Forceps Vacuum 
Maternal complications? Yes No   (abruption, maternal diabetes, cerclage, ect.)
Is child in daycare? Yes No Full time Part time 

Family Medical History
Please list all first-degree relatives with the following illnesses:

Heart Attack:               Stroke:
Diabetes:                High Blood Pressure:
Cancer:                    Sudden Death:
Other:
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Women Only

Last menstrual period: Do your periods come every month?  Yes  No If no how often?
Is you flow heavy light medium?        Do you get menstrual cramps? Yes No
How long does your period last?
Do you have pain or bleeding after sexual intercourse? Yes No
How many times have you been pregnant? How many miscarriages or abortions have you had?
How many times have you given birth?   How many children do you have?
What is your method of birth control?
Date of your last pap smear: Have you ever had an abnormal pap? Yes No
Do you get hot flashes? Yes No              Do you do self breast examinations? Yes No
When was your last mammogram/breast exam? Was it normal Yes No

Review of Systems
Please check if you have or had any of the following in the past six months:

Received by: _______________________________________________________            Date: ______________________