Today's date:
    Where did you hear about Revive Treatment Centers?
    Referrer name:











    In providing your mobile number and/or email address above, you grant Revive Centers the authorization to send you quarterly information regarding special announcements and opportunities.

    What is your height?: Weight:

    In your own words, why did you make an appointment to see the doctor? List in order of importance your main complaints or health goals.

    CURRENT MEDICATIONS: Please list all medications (prescription and non-prescription) and supplements taken regularly. If you already have a list, please bring it with you to your appointment.

    Current Medications:
    Dose (mg):
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    MEDICATION ALLERGIES:Please list all drug allergies and sensitivities and your reaction (e.g. Penicillin-rash)

    OTHER ALLERGIES:(Please include type of reaction:)

    PERSONAL MEDICAL HISTORY: Please check any current or past medical condition. IF IN THE PAST, please indicate date of treatment

    Condition

    Date of Treatment


























    Condition

    Date of Treatment

























    Please include any comments regarding the above treatments or any previous question that you feel are important

    SURGERY AND PROCEDURE HISTORY

    Hospitalizations
    Reason:
    Year:

    Reason:
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    SOCIAL HISTORY:
    Tobacco Use Quit date?
    Packs/day Number of years smoked

    Alcohol Use Amount per week?
    Do you crave alcohol?
    Have you ever felt guilty about the amount you drink or about needing to control your drinking?
    Drug Use
    If current or past use, please list:
    Caffeine Use Type and frequency of caffeine:
    Recent foreign travel When: Where:
    Exercise Preferred exercise: Times per week:
    Do you have any tattoos?
    Do you have any piercings?
    Are you sexually active? If yes, with

    FAMILY HISTORY: Please note the medical problems as appropriate of family members

    Mother




















    Father




















    Siblings




















    Grandparents




















    Children




















    GENERAL HEALTH REVIEW
    Please check the box of any of the symptoms that apply to you. We will discuss further at your visit.
    Have you had any weight loss or gain in the last year?
    If so, how much?

    Head/Eyes/Ears/Nose/Throat

    Dental Difficulties

    Cardiovascular

    Respiratory

    Hematological/Lymphatic

    Skin/Breast

    Gastrointestinal

    Genitourinary

    Endocrine

    Musculoskeletal

    Neurological

    Psychiatric/Depression

    If you checked any of the above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with people?

    Notes of explanation or clarification on ANY of the General Health Review symptoms above:

    Female Patients Only
    Age of onset of menses: First date of last period:

    How many times have you been pregnant? Number of live births:
    Miscarriages: Abortions:
    Premature births Complications
    C-sections

    PREVENTIVE CARE
    Please check if you have had these tests, and note the date of the most recent for each:
    Test/Procedure Date Result
    Last complete physical exam
    Cholesterol test
    Bone Density (DEXA)
    Colon Cancer Screen (colonoscopy, fecal occult blood test)
    Routine Eye Exam
    EKG (electrocardiogram)
    Mammogram
    Pap Smear

    Vaccinations Date
    Flu vaccine
    Prevnar 13 (pneumonia vaccine)
    Pneumovax (2nd pheumonia vaccine)
    TDAP vaccine (tetanus, diphtheria, pertussis)
    Measles vaccine
    Shingles vaccine
    Tuberculin PPD skin test

    Childhood Health
    Were you born:
    Were you breast fed?
    Recurrent health issues as a baby or child? List:
    Were you on antibiotics frequently as a child?
    Where did you grow up?

    Please check answers that apply:
    Please rate your overall health
    Please list what you have, on a typical day, for your meals:
    Breakfast:
    Lunch:
    Dinner:
    Snacks:
    Dessert:
    What type of diet do you follow? (Check all that apply)

    What types of food do you crave?

    Do you have any food allergies or sensitivities?

    Do you consume MSG or aspartame?

    Are you sensitive to MSG or aspartame?

    Are you sensitive to alcohol?

    Do you have an intolerance to fermented foods, such as yogurt, sauerkraut, pickles?

    Do you have an intolerance to sulphur-rich foods, such as onion, garlic, cruciferous vegetables?

    Have you been on fluoroquinolones antibiotic, such as Cipro or Levaquin?

    Readiness for healthy changes and wellness:
    Check the level that applies to you.
    I can make time for cooking
    I can make time for regular exercise
    I can make time for fun and pleasure
    I am willing to set new priorities
    I am willing to modify my diet
    I am willing to take nutritional supplements
    I will make changes to improve my health
    I am confident that I will follow through and persist
    What challenges do you expect to face when moving towards your healthcare goals?

    Quality of Life Assessment
    How do you rate your stress level?
    How do you cope with your stress?

    How many hours do you sleep at night?
    Do you wake feeling refreshed?
    Do you consider yourself to be a spiritual person?
    Do you meditate?
    How happy are you?

    What gives meaning to you in your life?

    Do you enjoy particular hobbies? Please list:

    What accomplishments are you most proud of?

    What three words would you choose to describe yourself?

    Do you participate in any professional or social organizations? Please list:

    Are there upcoming events you are looking forward to? Please list:

    What else would you like us to know about?

    Thank you for taking the time to review your health history.
    Sincerely,
    The Revive Team