Health History

If you prefer to provide us with a list of medications to import into your chart, please answer "See List" to this question.
You may also provide us with the name of a specialist that you see on a regular basis.
Please include the "location", for example, King Soopers @ Fillmore & Centennial

For Women Only

Form Validation

Or, if you are completing this form for someone else, please provide the patient's birth date.