Initial Health History

New Patient Intake and Annual Form

Please complete this form to share your health history with your provider.
Form found at: https://www.larimer.gov/health/clinical-services/clinic-forms
Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Reason for visit:

	Current	Past
Hormonal IUD (Mirena, Liletta, Skyla, Kyleena)
Non-hormonal IUD (Paragard)
Contraceptive implant (Nexplanon)
Depo shot (Depo Provera)
Vaginal ring (Nuvaring)
Birth control patch
Birth control pills
Condoms
Fertility-based awareness
Vasectomy or Tubal ligation
Emergency contraception
Other

	Yes	No
Endometriosis
Pelvic inflammatory disease (PID)
Ovarian cysts
Polycystic ovarian syndrome (PCOS)
Other uterine disorders

New Patient Intake and Annual Form