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1706 NW Glisan Street, Suite 2, Portland, OR 97209

Health History Questionnaire

Please note that it is important to fill in all the fields before submitting. Thank you.

General Patient Information

Patient Name :
*Last Name :
Middle Name : *First Name :
*Date of Birth :
Age : Occupation :
*Home Address
City :
State :
Zip :
*Home Phone # : () - -
Work Phone # : () - - -
Cell Phone # : () - -
*Email Address :
Emergency Contact Details
Contact Person Name : Phone # : () - -
Relationship of Contact :
*How did you hear about us:
What are your most important health concerns?
HOSPITALIZATION AND SURGERY
What hospitalizations or surgeries have you had?
MEDICATIONS OR SUPPLEMENTS
List medications or supplements that you currently take.
IMMUNIZATIONS
Have you had any of the following immunizations: Childhood diseases
Measles Diptheria Mumps
Rubella Polio Pertussis
Tetanus shot
Other :
X-RAYS AND SPECIAL
What diagnostic imaging studies have you had?
Electrocardiogram X-rays CT Scan
Bone Density Scan Mammogram MRI
Other :
ALLERGIES
Do you have allergies to: Vitamin B, foods, drugs, or allergens in your environment (cats, mold, dust)? If yes please explain.
Have you had any of the following?
Rheumatic Fever Diptheria Scarlet fever
Mumps German Measles Measles
Other :
SELF AND FAMILY HISTORY
Please list any disease that you or any family member currently has or has had in their life. Family members include parents, siblings, grandparents, aunts, uncles, and children. Please list all illnesses such as cancer, diabetes, heart disease, stroke, liver disease, kidney disease, asthma, mental illness, high blood pressure, etc.
HABITS
Awaken rested: Yes No
Sleep well: Yes No
Average 6-8 hours sleep: Yes No
Enjoy your work: Yes No
Spend time outside: Yes No
Take vacations: Yes No
Eat three meals daily: Yes No
Use recreational drugs: Yes No
Use tobacco: Yes No
Use alcoholic beverage: Yes No
Have you been treated for alcoholism: Yes No
Have you been treated for drug dependence: Yes No
Stress Level: 00 is stress-free and 10 is highly stressed  
What are your main interests and hobbies?
Do you exercise? Yes No How many days per week?
What type of exercise do you do?

REVIEW OF SYSTEMS

GENERAL
Weight :
Weight 1 year ago :
Maximum Weight :
When :
Height :
ENDOCRINE
Hypothyroid Heat or cold intolerance
Excessive thirst Excessive hunger
SKIN
Rashes Eczema, hives Acne, boils
Itching Color change Lumps
Night sweats
BLOOD
Anemia Easy bleeding or bruising
HEAD
Headache Head Injury
NECK
Lumps Swollen glands Goiter
Pain or stiffness
PERIPHERAL VASCULAR
Deep leg pain Cold hands/feet Varicose veins
Thrombophlebitis
FEMALE REPRODUCTIVE
Age menses began?
Average number of days?
Length of cycle?
Nipple discharge Bleeding between periods
Regular cycles Difficult conceiving
Menopausal symptoms Are you sexually active
Sexual difficulties Venereal disease
Self-breast exams Lumps
Pain or tenderness
NEUROLOGICAL
Fainting Seizures Paralysis
MUSCULOSKELETAL
Join pain or stiffness Arthritis
Broken bones Muscle spasms / cramps
Weakness
BOWEL MOVEMENTS
How often?
Is this a change? Yes No
Blood in stool Belching or passing gas
Jaundice (yellow skin) Liver disease
Hemorrhoids
EMOTIONAL
Depression Mood swings Tension
Anxiety or nervousness
NOSE AND SINUSES
Frequent colds Nose bleeds Stuffiness
Hay fever Sinus problems
GASTROINTESTINAL
Trouble swallowing Heartburn Change in thirst
Change in appetite Nausea Vomiting
Vomiting blood
MOUTH AND SINSUES
Gum problems Sore tongue Hoarseness
Dental cavities Frequent sore throats
RESPIRATORY
Cough Sputum
Spiting up blood Wheezing
Asthma Bronchitis
Pneumonia Pleurisy
Emphysema Difficulty breathing
Pain on breathing Tuberculosis
Shortness of breath
EYES
Impaired vision Glasses or contacts Eye Pain
Tearing or dryness Double vision Glaucoma
Cataracts
EARS
Impaired hearing Ringing Earache
Dizziness
CARDIOVASCULAR
Heart disease Angina
High blood pressure Murmurs
Muscle weakness Numbness or tingling
Loss of memory Rheumatic fever
Chest pain Swelling in ankles
Palpitations
MALE REPRODUCTIVE
Hernias Testicular masses
Testicular pain Sexually Active
Prostate disease Venereal disease
Discharge or sores
URINARY
Pain on urination Increased frequency
Frequency at night Inability to hold urine
Frequent infections Kidney stones

Refund Policy

Services:
  • All services need to be completed within 12 months from purchase/start date.
  • Our knowledgeable Thrive staff is always available to answer any questions you may have, please make informed purchases as no refunds can be made. We will gladly issue a Thrive credit toward future services upon approval of management.
Products:
  • Any unopened products returned with a receipt within 7 days may be issued a refund.
  • In general, products that have been opened may not be returned. Any exceptions are up to management’s discretion.
Cancellation Policy:
  • 48 Hour notice is required; otherwise a cancellation fee may be applied.
* I certify that the information that I have supplied is correct and accurate to the best of my knowledge.
*Patient / Legal Guardian Signature
Date