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S:\G_hlc\Business Team ACED Patient Information Sheet 11/30/09
Patient Information
Name:
______________________________________________________
Last
First
M.I.
SSN: _________________ Martial Status: S M D W
Sex: M F
Date of Birth _________ Phone:
Home Address:
City: __________________________ State: ___________ Zip:
Employer: _____________________________ Occupation:
Business address:
City: ________________________________ State: ______________ Zip:
Email : _______________________________ Primary Care Physician
Responsible Party
Name:
Last
First
M.I.
SSN: ______________________ Marital Status: S M D W
Sex: M F
Date of Birth ___________ Relationship to patient
Home Address: _____________________________ Phone:
City:___________________________ State:_________ Zip:
Employer: _______________________ Business Address:
City: ___________________ State: _______ Zip:
Insurance
Primary Carrier: _________________________ ID #
Group No. _____________________________ Copay
Coverage: Spouse Dependent Self
Secondary Carrier: _______________________ ID #
Group No. _____________________________ Copay
Coverage: Spouse Dependent Self
Financial Agreement and Authorization for Treatment and Release of Medical Information
I authorize treatment of the person named above and agree to pay all fees and charges for such treatment. I
understand that all charges are due and payable at the time of service. I am also aware that if insurance does not
cover services I am responsible for all charges. I understand that ACED reserves the right to charge and collect $20 for
any missed appointment without cancellation. I authorize payment of insurance benefits directly to ACED. I authorize
release of medical information needed to complete insurance company claim inquiries, quality assurance and
utilization management activities.
Signature:______________________________________________ Date:

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S:\G_hlc\Business Team ACED Patient Information Sheet 11/30/09
The professionals at Advanced Care in Endocrinology and Diabetes are committed to safeguarding the
privacy and confidentiality of your medical record including the personal information that you share with
us. We comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
From time to time it may be necessary or desirable to contact patients by phone. To
expedite your health care and in the interest of convenience, if you are not available to
speak with us directly, we would like to leave a message whenever possible.
To assist us in protecting your privacy, please complete the following:
Patient Name:
DOB:
(Please print)
I WISH TO BE CONTACTED IN THE FOLLOWING MANNER (FILL IN/CIRCLE ALL THAT APPLY)
Primary Phone: ____________________________________________
Leave a detailed voice mail message?
Y N
Leave a message with call back number?
Y N
Email Address: ____________________________________________
Leave a message to call us?
Y N
Other request: _________________________________________________________________
May we speak to someone else regarding your medical care?
Y N
Name of person:
Relationship
______________________________________ ___________________________________
______________________________________ ___________________________________
I have been made aware of the privacy policies of ACED and have received (or reviewed or been given the
option to receive) a copy of the HIPPA Notice of Privacy Practices. I understand I may revoke this consent
at any time.
Signed: ________________________________ Date: _______________________________
Relationship to Patient:__________________________________________________________
Witness: ______________________________________________________________________
Acknowledgement of Privacy and Confidentiality Policy
• If I am not available, I acknowledge that personal and confidential medical information about me
may be left with the person I named above.
• I do so voluntarily and by signing below, I waive this confidentiality.
• It may be left on my answering machine if indicated above.
• I am aware that this permission can be revoked at any time.
Patient Signature: ______________________________________Date: ___________________

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S:\G_hlc\Business Team ACED Patient Information Sheet 11/30/09
Advanced Care in Endocrinology and Diabetes
3207 North Academy Blvd
Colorado Springs, CO 80917
Phone: (719) 776-ENDO (3636) Fax: (719) 776-3610
New Patient Form
1. LAST NAME: ________________________________________________________________
2. FIRST NAME AND MIDDLE INITIAL: ______________________________________________
3. DATE OF BIRTH: ______________________________________________________________
4. HOME ADDRESS: _____________________________________________________________
___________________________________________________________________________
5. HOME PHONE NUMBER: _______________________________________________________
6. WORK PHONE NUMBER: _______________________________________________________
7. CELL PHONE NUMBER: ________________________________________________________
8. DO YOU USE TEXT MESSAGES (SMS): □ YES
□NO
9. EMAIL ADDRESS: _____________________________________________________________
10. EMERGENCY CONTACT PERSON: ________________________________________________
11. EMERGENCY CONTACT PHONE NUMBER: _________________________________________
12. MY PRIMARY DOCTOR IS: ______________________________________________________
13. PHARMACY PHONE NUMBER: __________________________________________________
14. SOCIAL SECURITY NUMBER: ____________________________________________________
15. OCCUPATION: _______________________________________________________________
16. HOBBIES: ___________________________________________________________________
17. HIGHEST LEVEL OF EDUCATION: □ MIDDLE SCHOOL □HIGH SCHOOL □COLLEGE □GRADUATE
18. DO YOU WEAR YOUR SEATBELT ON A REGULAR BASIS? □ NO
□YES
19. HOW OFTEN DO YOU EXERCISE ON AVERAGE WEEK? □ 0-2 DAYS □ 3-5 DAYS □ 6-7 DAYS
20. DURATION OF YOUR EXERCISE/WALK/BIKING PER SESSION? □ 0-30 MIN □ 31-60 MIN □ ABOVE 1 HR
21. WOULD YOU CHARACTERIZE YOUR DIET AS:
□ WESTERN □MEDITERRANEAN □LOW FAT □ LOW CARB □ VEGETARIAN □ OTHER ___
22. DO YOU PRESENTLY SMOKE/USE TOBACCO? □NO □YES, HOW MANY PACKS A DAY? ______
HAVE YOU EVER SMOKED? □ NO □ YES, QUIT WHEN _____________________________
23. DO YOU CURRENTLY CONSUME MORE THAN 2 ALCOHOL DRINKS A DAY? □ NO □ YES
24. DO YOU CURRENTLY USE OR USED IN THE PAST RECREATIONAL DRUGS? □ NO □YES

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S:\G_hlc\Business Team ACED Patient Information Sheet 11/30/09
MEDICAL HISTORY
I NEED TO SEE ENDOCRINOLOGIST FOR _______________________________________
I HAVE THE FOLLOWING MEDICAL CONDITIONS:
1. __________________________________
6. _________________________
2. __________________________________
7. _________________________
3. __________________________________
8. _________________________
4. __________________________________
9. _________________________
5. __________________________________
10. ________________________
I HAD THE FOLLOWING SURGERIES OR WAS HOSPITALIZED FOR:
1. __________________________________
4. _________________________
2. __________________________________
5. _________________________
3. __________________________________
6. _________________________
I AM TAKING THESE MEDICINES, VITAMINS, SUPPLEMENTS, HERBS (NAME, DOSE, FREQUENCY):
NAME (example, Lipitor) DOSE (example, 10 MG) FREQUENCY (example, once a day)
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
5. ___________________________________________________________________________
6. ___________________________________________________________________________
7. ___________________________________________________________________________
8. ___________________________________________________________________________
9. ___________________________________________________________________________
10. ___________________________________________________________________________
11. ___________________________________________________________________________
12. ___________________________________________________________________________
13. ___________________________________________________________________________
14. ___________________________________________________________________________
I AM ALLERGIC TO THE FOLLOWING MEDICATIONS:
______________________________________________________________________________
______________________________________________________________________________

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S:\G_hlc\Business Team ACED Patient Information Sheet 11/30/09
DATE OF LAST PHYSICAL EXAM (month/year): _______________
DATE OF LAST EYE EXAM (month/year): ____________________
DATE OF LAST FOOT EXAM (month/year): __________________
DATE OF LAST DENTAL EXAM (month/year): ________________
DO YOUR PARENTS OR BROTHERS/SISTERS/CHILDREN HAVE OR HAD:
HEART ATTACK/HEART BYPASS SURGERY/STENT? □DON’T KNOW □ NO □YES, AT AGE: ________
STROKE?
□ DON’T KNOW □ NO □YES
HIGH CHOLESTEROL? □ DON’T KNOW □NO □YES
OBESITY? □ DON’T KNOW □ NO □ YES
ADULT DIABETES? □ DON’T KNOW □ NO □ YES
JUVENILE, TYPE 1 DIABETES? □ DON’T KNOW □ NO □ YES
THYROID DISEASE? □ DON’T KNOW
□NO
□ YES, WHAT KIND? ___________________
CANCER? □ DON’T KNOW □ NO □ YES, IN WHAT ORGAN DID IT START? ______________________
OSTEOPOROSIS, HIP FRACTURE? □DON’T KNOW □ NO □ YES, AT AGE: ___________________
RHEUMATOID ARTHRITIS, LUPUS, MULTIPLE SCLEROSIS, ALS? □ DON’T KNOW □ NO □ YES
PLEASE MARK ANY OF THE FOLLOWING SYMPTOMS THAT YOU ARE HAVING:
GENERAL: □ UNEXPLAINED RAPID WEIGHT GAIN
□ FEVER
□ UNEXPLAINED RAPID WEIGHT LOSS
□ EXTREME TIREDNESS
EYES:
□ EYE LASER TREATMENTS
□ GLAUCOMA
□ POOR VISION/BLINDNESS
□ MACULAR DEGENERATION
□ TUNNEL VISION (POOR PERIPHERAL VISION)
□ DOUBLE VISION
□ CATARACTS
□EYES DRY/ITCHING/BURNING
□ COLOR BLINDNESS
□ RETINAL DETACHMENT
ENT:
□ LOSS OF HEARING/DEAFNESS
□BUZZING/RINGING IN THE EARS
□ MOUTH DRYNESS
□ DIFFICULTY SWALLOWING
□ CHANGES IN VOICE, HOARSENESS
□PAIN IN FRONT OF THE NECK
□ ENLARGED THYROID OR NECK LUMPS
□ IMPAIRED SMELL OR TASTE
□ BLEEDING GUMS
□ DENTURES/BRIDGES
HEART/RESPIRATORY:□ ASTHMA OR COPD
□ SLEEP APNEA
□ USE OXYGEN
□ USE CPAP/BIPAP
□ SHORTNESS OF BREATH ON EXERTION
□SHORT OF BREATH AT NIGHT/REST
□ BLOOD IN SPUTUM
□ LONG TERM COUGH
□ CHEST/ARM/JAW/TEETH DISCOMFORT ON EXERTION □ CALF PAIN WHILE WALKING
□ SLOW, FAST OR IRREGULAR HEART BEAT
□ LOW BLOOD PRESSURE
□ ANKLE/LEG SWELLING WITH WATER
□ POOR HEALING LEG ULCERS
□ PACEMAKER OR INTERNAL DEFIBRILLATOR
GASTROINTESTINAL: □ NAUSEA
□ VOMITING
□ EARLY SATIETY
□ EATING DISORDER (ANOREXIA)
□ DIARRHEA
□ CONSTIPATION
□ IRRITABLE BOWEL
□ CROHN DISEASE OR COLITIS
□ FREQUENT HEARTBURN, INDIGESTION
□ ABDOMINAL PAIN
□ BLOODY OR BLACK LIKE A TAR STOOLS
□ STOOL INCONTINENCE
□ FOOD INTOLERANCES _________________________________________________________
BREAST:
□ NIPPLE DISCHARGE
□ BREAST LUMP/MASS
□ BREAST PAIN/TENDERNESS OR SWELLING

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S:\G_hlc\Business Team ACED Patient Information Sheet 11/30/09
BLOOD:
□ HISTORY OF BLOOD CLOTS
□ BLEEDING PROBLEMS
□ EASY BRUISING
□ ANEMIA
HAVE YOU EVER HAD RADIATION TREATMENTS TO HEAD, NECK OR WHOLE BODY □ YES □NO
UROLOGICAL: □ FREQUENT BLADDER OR VAGINAL INFECTIONS
□ KIDNEY PROBLEMS
□ KIDNEY STONES
□ FREQUENT URINATION
MEN ONLY: □ PAIN OR LUMP IN TESTICLES
□ STD/DISCHARGE
□ DIFFICULTIES ACHIEVING OR MAINTAINING ERECTIONS □ PREMATURE EJACULATIONS
□ CHANGE IN DESIRE TO HAVE SEXUAL INTIMACY (LIBIDO) □ OTHER ISSUES
WOMEN ONLY: □ DATE OF LAST PERIOD ______________
ARE YOU PREGNANT NOW? □NO □ YES
NUMBER OF PREGNANCIES __________ LIVE BIRTHS _____
□ IRREGULAR PERIODS
□ SPOTTING BETWEEN PERIODS
□ VAGINAL DRYNESS
□ PAINFUL INTERCOURSE
□ ABSENCE OF ORGASMS
□ LACK OF INTEREST IN SEX
□ DO YOU USE ANY FORM OF CONTRACEPTION (BIRTH PILL, DEVICE, CONDOMS)
MUSC/BONES: □ MUSCLE ACHES
□ MUSCLE WEAKNESS
□ GOUT
□ ARTHRITIS
□ FRACTURES
□ AMPUTATIONS
NEURO/PSYCH:□ FREQUENT SEVERE HEADACHES
□ DIZZINESS
□ PREVIOUS HEAD INJURY
□ UNSTEADY GAIT
□ SEIZURES
□ LOSS OF CONSCIOUSNESS
□ PARALYSIS
□ TREMOR
□ BURNING, SHOOTING PAIN IN HANDS/FEET
□ DECREASED SENSATION/FEET
□ MEMORY LOSS
□ DEPRESSION/ANXIETY/FEARS
ENDOCRINE: □ EXCESSIVE SWEATING / NIGHT SWEATS
□ LOW BLOOD SUGAR
□ CALCIUM PROBLEMS
□ POTASSIUM PROBLEMS
□ HEAT/COLD INTOLERANCE
□ ADRENAL PROBLEMS
□ THYROID PROBLEMS
□ PITUITARY PROBLEMS
SKIN: □ FOOT/LEG ULCERS
□ SKIN RASH
□ DARKENING OR LIGHTENING OF THE SKIN
□ DRY SKIN
□ HAIR LOSS
□ BRITTLE NAILS
ANYTHING ELSE YOU WOULD LIKE US TO KNOW ABOUT YOU? ________________________________________
__________________________________________________________________________________________
Do you have good understanding of your illnesses or conditions? □ No □ Yes
Do you understand instructions that your doctor gives you about your illnesses or conditions? □ No □ Yes
Are you having a problem dealing with any of your illnesses or medical conditions? □ No □ Yes
Where do you get help/support with your problems? □ Family □ Friends □ Church □ None □ Other
Who do you prefer to make decisions concerning your care? □ Self □ Physician □ Family member □ Friend
I hereby certify that the answers given are true and complete to the best of my knowledge. I hereby
understand that this information will remain confidential within Penrose-St Francis Health Services. I hereby
authorize Penrose-St Francis to release any information acquired in the course of my treatment to any
physician or health organization as required.
SIGNATURE: __________________________
For office use only: JJJJJJJJJJJJJJJJJJJJJJJ
Reviewed: JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ
JJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ

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Acknowledgment Form
By signing below I acknowledge my understanding and agreement with the following terms
and conditions:
❖ “Advanced Care in Endocrinology and Diabetes” is a consultative practice. Our
aim is to aid your primary care provider and you in the management of complex
metabolic and hormonal conditions. The physicians employed by the practice do
not become primary care providers for the patient. It is patient’s responsibility to
establish and maintain a primary care provider for all ongoing and future health
care needs.
❖ Currently there is no physician on call for “Advanced Care in Endocrinology and
Diabetes” who would be available for home or hospital visits, or who could
provide care when the office is closed, i.e. after regular business hours, on the
weekends, when the doctor is away on sick leave, vacation, business meeting,
etc. In case of medical emergency the patient will to use one of the following
resources for help – 911 service, nearest hospital emergency department or
urgent care, primary care provider.
As the practice grows and changes the current rules may change. We hope to be able to
provide an expanded range of services in the future. Any changes to the current rules will
be discussed during the regularly scheduled appointments. Please let the office know if
you have any questions or concerns regarding this information.
Thank you for allowing us to provide care to you. Your health and well-being is important
to us.
________________________
______________________
Signature
Date