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GRAND JUNCTION: 970-644-5999 | MONTROSE: 970-240-8199
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Form: Complete Adult Health History

Form: Complete Adult Health HistoryLong Point Digital2019-08-08T08:58:32-06:00

Step 1 of 6 - Patient Info

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  • 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.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • MEDICAL HISTORY

  • Please list any surgeries or hospital stays you have had and their approximate date/year:
  • Type of Surgery:Date: 
  • 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 NameDosage 
  • Are you currently receiving care from any other doctors, chiropractors, or other health care professionals? If yes, we would like to know whom so that we can coordinate your care:
  • Provider’s nameCondition they are treating you for 
  • Please note dates of your most recent immunizations:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • If you have had any of the following tests done, please note when the tests was done and what the results were, if known:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • FAMILY HISTORY

  • Check any of the diseases that run in your family and please note who had it:
  • HEALTH HABITS

  • PERSONAL HISTORY

  • SEXUAL HISTORY

  • WOMEN ONLY

  • OTHER COMMENTS:

  • This field is for validation purposes and should be left unchanged.

Grand Junction

  • 235 N. 7th Street,
    Grand Junction, CO 81501
  • 970-644-5999
  • info@trailheadclinics.com
Mon - Fri: 8am-5pm
Sat-Sun: Closed

Montrose

  • 401 South Park Avenue,
    Montrose, CO 81401
  • 970-240-8199
  • info.montrose@trailheadclinics.com
Mon - Fri: 8am-5pm
Sat-Sun: Closed

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