www.thriveportland.com - Health History Questionnaire

Please note that it is important to fill in all the fields before submitting. Thank you.
General Patient Information
Patient Name :*

First NameMiddle NameLast Name
Date of Birth :*

DayMonthYear
Age : *
Occupation :*
Address :*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone # :*
Work Phone # :
Cell Phone # :
Email :
Emergency Contact Details
Contact Person Name :
Phone # :
Relationship of Contact :
How did you hear about us :*
Type a question
What are your most important health concerns?
HOSPITALIZATION AND SURGERY
What hospitalizations or surgeries have you had?
X-RAYS AND SPECIAL
What diagnostic imaging studies have you had?

ElectrocardiogramX-raysCT ScanBone Density ScanMammogramMRIOther
MEDICATIONS OR SUPPLEMENTS
List medications or supplements that you currently take :
ALLERGIES
Do you have allergies to: Vitamin B, foods, drugs, or allergens in your environment (cats, mold, dust)? If yes please explain :
IMMUNIZATIONS
Have you had any of the following?

Rheumatic FeverDiptheriaScarlet feverMumpsGerman MeaslesMeaslesOther
Have you had any of the following immunizations: Childhood diseases

MeaslesDiptheriaMumpsRubellaPolioPertussisTetanus shotOther
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 :

YesNo
Use recreational drugs :

YesNo
Sleep well :

YesNo
Use tobacco :

YesNo
Average 6-8 hours sleep :

YesNo
Use alcoholic beverage :

YesNo
Enjoy your work :

YesNo
Have you been treated for alcoholism :

YesNo
Spend time outside :

YesNo
Have you been treated for drug dependence :

YesNo
Take vacations :

YesNo
Eat three meals daily :

YesNo
Stress Level: 00 is stress-free and 10 is highly stressed
What are your main interests and hobbies?
Do you exercise?

YesNo
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 :
EMOTIONAL
DepressionMood swingsTensionAnxiety or nervousness
NOSE AND SINUSES
Frequent coldsNose bleedsStuffinessHay feverSinus problems
ENDOCRINE
HypothyroidHeat or cold intoleranceExcessive thirstExcessive hunger
GASTROINTESTINAL
Trouble swallowingHeartburnChange in thirstChange in appetiteNauseaVomitingVomiting blood
SKIN
RashesEczema, hivesAcne, boilsItchingColor changeLumpsNight sweats
MOUTH AND SINSUES
Gum problemsSore tongueHoarsenessDental cavitiesFrequent sore throats
BLOOD
AnemiaEasy bleeding or bruising
HEAD
HeadacheHead Injury
HEAD
LumpsSwollen glandsGoiterPain or stiffness
RESPIRATORY
CoughSputumSpiting up bloodWheezingAsthmaBronchitisPneumoniaPleurisyEmphysemaDifficulty breathingPain on breathingTuberculosisShortness of breath
PERIPHERAL VASCULAR
Deep leg painCold hands/feetVaricose veinsThrombophlebitis
EYES
Impaired visionGlasses or contactsEye PainTearing or drynessDouble visionGlaucomaCataracts
EARS
Impaired hearingRingingEaracheDizziness
FEMALE REPRODUCTIVE
Age menses began?
Average number of days?
Length of cycle?
Nipple dischargeBleeding between periodsRegular cyclesDifficult conceivingMenopausal symptomsAre you sexually activeSexual difficultiesVenereal diseaseSelf-breast examsLumpsPain or tenderness
CARDIOVASCULAR
Heart diseaseAnginaHigh blood pressureMurmursMuscle weaknessNumbness or tinglingLoss of memoryRheumatic feverChest painSwelling in anklesPalpitations
NEUROLOGICAL
FaintingSeizuresParalysis
MUSCULOSKELETAL
Join pain or stiffnessArthritisBroken bonesMuscle spasms / crampsWeakness
MALE REPRODUCTIVE
HerniasTesticular massesTesticular painSexually ActiveProstate diseaseVenereal diseaseDischarge or sores
BOWEL MOVEMENTS
How often?
Is this a change?

YesNo
Blood in stoolBelching or passing gasJaundice (yellow skin)Liver diseaseHemorrhoids
URINARY
Pain on urinationIncreased frequencyFrequency at nightInability to hold urineFrequent infectionsKidney 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.
Name of the Patient / Legal Guardian :
Date :

DayMonthYear
Should be Empty: