• Welcome to Associated Endocrinologists!  We ask you to please fill out and submit this new patient questionnaire PRIOR to your visit to speed up the check-in process. 

    Do the best you can -- we understand that some answers will require an explanation which we can discuss at your visit.

  • New Patient Questionnaire

  • What is your Gender?*
  • What is the primary reason for your visit?:*

  • MEDICAL HISTORY

  • Past Medical History (check off all that apply and type in other conditions not listed in the box below:
  • Do you take Biotin or a Biotin-containing supplement?
  • Do you have any medication allergies?*
  • Marital Status?*

  • Do you use or do you have history of using tobacco?*
  • How often do you consume alcohol on average?*

  • REVIEW OF SYSTEMS

    Please check any current symptoms you are experiencing
  • General*
  • Head*
  • Neck*
  • Heart*
  • Lungs*
  • GI*
  • Urinary*
  • Reproductive*
  • Musculoskeletal*
  • Skin*
  • Neurological*
  • Psychiatric*

  • Diabetes Questionnaire

    Please complete this section only if you are being seen for diabetes.
  • How many times per day do you check your blood sugar on average? (Reminder: bring your meter with you to your visit!)
  • List your typical range of blood sugars:
    Rows
  • If you use a CGM, what brand do you wear?
  • If you use an insulin pump, what brand do you wear?

  • Osteoporosis Questionnaire

    Please complete this section only if you are being seen for calcium related issues, kidney stones, low bone density, osteopenia, or osteoporosis.
  • What is your ethnicity

  • Have you ever broken any bones?
  • If you have ever broken a bone, please specify:
    Rows
  • Please indicate if you have had any of the following:
  • History Questions:
    Rows
  • How many servings of coffee/caffeine do you drink on average per day?
  • How many ounces of soft-drinks do you drink on average per day?
  • How many servings of dairy products to you consume on average each day? (one serving = 8 oz milk, 1 oz cheese, 1 cup yogurt or ice cream, 4 oz cottage cheese)
  • Do you take calcium supplements? If yes, how much?

  • Do you take Vitamin D supplements? If yes, how much?

  • Have you been treated with steroids previously?

  • Previous Osteoporosis Medications:
    Rows
  • Are you or have you been on any of these medications?
    Rows

  • Final Submission

    Please hit the submit button below to send your completed questionnaire to the office.  If you want to make any further edits, please hit the back button and them return to this screen to submit. We look forward to meeting you at your appointment.
  • Should be Empty: