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 :

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?

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?

Have you had any of the following immunizations: Childhood diseases

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 :

Use recreational drugs :

Sleep well :

Use tobacco :

Average 6-8 hours sleep :

Use alcoholic beverage :

Enjoy your work :

Have you been treated for alcoholism :

Spend time outside :

Have you been treated for drug dependence :

Take vacations :

Eat three meals daily :

Stress Level: 00 is stress-free and 10 is highly stressed

What are your main interests and hobbies?

Do you exercise?

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

NOSE AND SINUSES

ENDOCRINE

GASTROINTESTINAL

SKIN

MOUTH AND SINSUES

BLOOD

HEAD

RESPIRATORY

PERIPHERAL VASCULAR

EYES

EARS

FEMALE REPRODUCTIVE

Age menses began?

Average number of days?

Length of cycle?

CARDIOVASCULAR

NEUROLOGICAL

MUSCULOSKELETAL

MALE REPRODUCTIVE

BOWEL MOVEMENTS

How often?

Is this a change?

URINARY

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.

Name of the Patient / Legal Guardian :

Date :