• Patient Information

    This information will be sent to your provider and will be kept as part of your patient records.
  • Date
     - -
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birthdate
     - -
  • Format: (000) 000-0000.
  • Birthdate
     - -

  • Medications

  • Format: (000) 000-0000.

  • PFM Providers Will Not Provide Chronic Pain Medication Such As Prescription Opiate

    If you are seeing a specialist for your pain, please list:

  • Current Pain Medications

  • Other Current Medications

  • Allergies to Medications

  • Medical History

    Please check if you have/have had the following problems.
  • Problems

  • Past Surgical History

  • Family History

  • Rows

  • Health Maintenance

    Females
  • Are you still getting pap smears?
  • Date of last pap smear
     - -
  • Have you ever had an abnormal one?
  • Are you getting mammograms?
  • Date of mammogram
     - -
  • Have you ever had an abnormal one?
  • Have you had a bone density screening done?
  • Have you ever had a colonoscopy?

  • Males

  • Have you had a colonoscopy?
  • Have you ever had a PSA (prostate) screening done?

  • Social History: 

    (We recognize that these questions are sensitive. However, completing this section will help us better care for you.)

  • Do you have difficulty doing any of the following:

  • Concentrating, remembering, or making decisions?
  • Doing errands alone?
  • Dressing or bathing?
  • Driving at night?
  • Walking or climbing stairs?
  • Is it difficult to pay heat, water, or electricity bills?
  • Do you have a consistent place to live?
  • Do you go hungry because you do not have enough food?
  • Do you feel safe in your current living situation?
  • Do you have problems with transportation?
  • How often do you exercise?
  • Stress Level

  • Over the past 2 weeks, how often have you been bothered by any of the following:

  • Little interest or pleasure in doing things
  • Feeling down depressed or hopeless
  • Do you currently consume alcohol?
  • Do you currently use tobacco products: Smoking?
  • Do you currently use tobacco products: Chewing tobacco?
  • Do you use any other recreational drugs?
  • Caffeine intake
  • Do you use your seatbelt on a routine basis?
  • Do you regularly use sunscreen?
  • Do you have carbon monoxide and smoke detectors in your home?
  • Do you have an Advanced Directive?If yes, please bring a copy for your chart.

  • Previous Doctor

  • By signing below, I agree that the above information is true and correct. I authorize Pavilion Family Medicine to leave a voice mail on the phone number(s) above unless otherwise noted. Should there be any missing information, Pavilion Family Medicine may refuse service. By signing this, I also acknowledge receipt of Pavilion Family Medicine HIPAA Privacy Act Policy. This indicates Pavilion Family Medicine participates with Colorado Prescription Monitoring Program and Quality Health Network which is a centralized data base for healthcare professional and authorize prescription history consent. I hereby give a lifetime authorization for payment for insurance benefits to be made directly to Pavilion Family Medicine. I understand I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections, and reasonable attorney fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

  • Date
     - -
  • Should be Empty: