Initial Health History

  • New Patient Intake and Annual Form

    Please complete this form to share your health history with your provider.

  • Please complete this form only if you have a scheduled appointment and clinical staff requested you complete this form. If you need to schedule an appointment please call 970-498-6700. Thank you.

     

     

  • Form found at: https://www.larimer.gov/health/clinical-services/clinic-forms

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  • General Health and Social History

    Including Substance Use and Relationships
  • Would you like support with your nutrition and or physical fitness?
  • Do you currently or have you ever used any form of tobacco or nicotine, including vaping?
  • In the past year, have you used a recreational or a prescription drug for non-medical reasons?
  • Have you or your partner injected or snorted drugs in the past year?
  • Have you or your partner(s) exchanged sex for money or drugs in the past year?
  • Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?
  • Do you feel safe in your current relationship?
  • Is there anyone in your life who makes you feel unsafe now?
  • Has a partner ever forced or pressured you to do something sexually that you did not want to do?
  • If you are under 18, do you have a trusted adult to talk to about relationships, sex, and birth control?

  • Medical History

    Personal and Family History
  • Have you had any of the following conditions (check all that apply)?
  • Did/do your parents or siblings have cancer, diabetes, genetic conditions or heart disease?

  • Sexual Health History

  • Do you have sex with individuals that identify as (check all that apply):
  • What type(s) of sexual activity do you have (check all that apply)?
  • Has your current sexual partner(s) had other partners besides you in the past 3 months?
  • If you have had sex with a male partner, have they had sex with other males?
  • Do you have any or have you had any sexually transmitted infections (STIs)?
  • Are you currently having any symptoms of an STI?

  • Birth Control

  • Do you think you might like to have (more) children at some point?
  • Rows
  • How often do you use condoms?
  • Have you had vaginal sex without birth control since your last period?

  • Reproductive Health (Male/assigned male at birth)

  • Do you have any concerns with your penis or testicles?

  • Reproductive Health (Female/assigned female at birth)

  • Do you have any concerns with breast or reproductive health?
  • Rows
  • Is your flow:
  • Have you ever had an abnormal pap or positive HPV test?
  • Rows
  • Have you been pregnant in the last year?
  • During pregnancy, did you have high blood pressure, diabetes, or other complications?
  • Are you currently breastfeeding?

  • Thank you! Please click "submit" below to share this health information with your provider.

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