Your answers to the following questions will help us to understand your medical history and the concerns you’d like to discuss with your doctor. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering them, leave them blank. Thank you for your help.
Which location would you like to visit?*
Patient Name:*
Patient Date of Birth:*
MM slash DD slash YYYY
Phone*
Email*
Do you have a medical history to report?*
- YES, see answers below
- NO
Please check to indicate if you have ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Other
Please describe the condition
Are you currently taking prescription medications?*
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which you are currently taking. Please note the dosage if possible.
Medication Name Dosage
Would you like to add a family member?*
- YES
- NO
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
Additional Family Member
Family Member Name
First Last
Family Member Date of Birth
MM slash DD slash YYYY
Do you have a medical history to report?
- YES, see answers below
- NO
Please check to indicate if your family member has ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Family Member Other
Please describe the condition
Are you currently taking prescription medications?
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.
Medication Name Dosage
Would you like to add a family member?
- YES
- NO
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
2nd Additional Family Member
Family Member Name
First Last
Family Member Date of Birth
MM slash DD slash YYYY
Do you have a medical history to report?
- YES, see answers below
- NO
Please check to indicate if your family member has ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Family Member Other
Please describe the condition
Are you currently taking prescription medications?
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.
Medication Name Dosage
Would you like to add a family member?
- YES
- NO
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
3rd Additional Family Member
Family Member Name
First Last
Family Member Date of Birth
MM slash DD slash YYYY
Do you have a medical history to report?
- YES, see answers below
- NO
Please check to indicate if your family member has ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Family Member Other
Please describe the condition
Are you currently taking prescription medications?
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.
Medication Name Dosage
Would you like to add a family member?
- YES
- NO
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
4th Additional Family Member
Family Member Name
First Last
Family Member Date of Birth
MM slash DD slash YYYY
Do you have a medical history to report?
- YES, see answers below
- NO
Please check to indicate if your family member has ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Family Member Other
Please describe the condition
Are you currently taking prescription medications?
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.
Medication Name Dosage
Would you like to add a family member?
- YES
- NO
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
5th Additional Family Member
Family Member Name
First Last
Family Member Date of Birth
MM slash DD slash YYYY
Do you have a medical history to report?
- YES, see answers below
- NO
Please check to indicate if your family member has ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Family Member Other
Please describe the condition
Are you currently taking prescription medications?
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.
Medication Name Dosage
Would you like to add a family member?
- YES
- NO
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
6th Additional Family Member
Family Member Name
First Last
Family Member Date of Birth
MM slash DD slash YYYY
Do you have a medical history to report?
- YES, see answers below
- NO
Please check to indicate if your family member has ever had the following conditions:
- Diabetes (250.00)
- High blood pressure (401.9)
- Asthma (493.20)
- Heart attack (411.89)
- Kidney disease (588.8)
- Hepatitis (571.40)
- Thyroid disease (244.9 hypo; 242.9 hyper)
- Stroke (436)
- Depression (311)
- Emphysema (496)
- Seizures (345.10)
- Tuberculosis (011.90)
- Coronary Artery Disease (414.00)
- Congestive Heart Failure (428.00)
- Arrythmia (427.9)
- Sexually transmitted disease
- Eye problems
- Cancer
- Other
Family Member Other
Please describe the condition
Are you currently taking prescription medications?
- YES, see answers below
- NO
Please list all medications, including vitamins, herbal or natural supplements and prescription medications, which your family member is currently taking. Please note the dosage if possible.
Medication Name Dosage
If you need to add additional family members please give us a call at 970-644-5999 after you have submitted your entries.
Agreement
- I consent to having Trailhead Clinics' website store my submitted information so they can respond to my inquiry.
Comments
This field is for validation purposes and should be left unchanged.

Medication Name	Dosage

Medication Name	Dosage

Medication Name	Dosage

Medication Name	Dosage

Additional Family Member

2nd Additional Family Member

3rd Additional Family Member

4th Additional Family Member

5th Additional Family Member

6th Additional Family Member