Today's date: Where did you hear about Revive Treatment Centers? —Please choose an option—Doctor ReferralFamily Or FriendSocial MediaGoogleOther Referrer name: Your first name: Your last name: Age: Address: City: State: Zip: Home Phone: Mobile Phone: Email: Date of Birth: Occupation: 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): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Medications: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): Current Supplements: Dose (mg): Frequency: Reason for use (if known): 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 Acid RefluxAdrenal FatigueAlcoholismAllergies/Hay feverAnemiaAnxietyAsthmaAuto-immune disorderBlood TransfusionsCancerCeliac DiseaseCongestive Heart FailureCysts on breasts or ovariesDepressionDiabetesEpilepsy Liver DiseaseFrequent Colds/IllnessesGlaucomaHeart DiseaseHeart PacemakerHeart MurmurHepatitisHigh CholesterolHigh Blood PressureInflammatory Bowel Disease (e.g. Crohn's, colitisKidney infections or stones Date of Treatment Condition MigrainesMultiple SclerosisMuscle crampsObesityOld heart attackOsteoporosisParalysisPoor circulationPulmonary disease/COPDRaynaud's PhenomenonRestless Leg SyndromeRheumatic FeverRheumatoid ArthritisSexual ProblemSexually Transmitted DiseaseSmall Intestinal Bacterial OvergrowthSleep ApneaSkin IssuesStomach ulcerStrokeTerminal IllnessThick Sinus SecretionsThyroid DiseaseTuberculosisYeast overgrowthOther Date of Treatment Please include any comments regarding the above treatments or any previous question that you feel are important SURGERY AND PROCEDURE HISTORYNo prior surgical historyAppendectomyBreast lumpectomyCataract surgeryColon surgeryD & C (female)Gall bladder surgeryHeart surgeryHemorrhoidsHerniaHysterectomyMastectomyBack or spine surgeryTonsilectomyTubal ligationC-Section (female)Other: Hospitalizations Reason: Year: Reason: Year: Reason: Year: Reason: Year: Reason: Year: Reason: Year: Reason: Year: Reason: Year: SOCIAL HISTORY: Tobacco UseNone Quit date? Pipe/CigarCigarettes Packs/day Number of years smoked Smokeless tobaccoElectronic/e-cigaretteSecond-hand smoke exposure Alcohol UseNoneDailyOccasionallyIn recovery Amount per week? Do you crave alcohol? YesNo Have you ever felt guilty about the amount you drink or about needing to control your drinking? YesNo Drug UseNonePast useCurrently If current or past use, please list: Caffeine UseNone Type and frequency of caffeine: Recent foreign travelNone When: Where: ExerciseNever Preferred exercise: Times per week: Do you have any tattoos? YesNo Do you have any piercings? YesNo Are you sexually active? YesNo If yes, with —Please choose an option—male spouse/partnerfemale spouse/partnermenwomenboth FAMILY HISTORY: Please note the medical problems as appropriate of family members I am adoptedUnknown Parental/Family History Mother Age if living/Age deceased Cause of death Alcoholism Anemia Asthma Heart Disease Cancer Depression Diabetes Gastroesophageal reflux disease High Cholesterol High Blood Pressure Thyroid Disease Kidney Disease Liver Disease Osteoarthritis Colon Cancer Pulmonary Disease Stroke Neurological (MS, etc) Autoimmune Father Age if living/Age deceased Cause of death Alcoholism Anemia Asthma Heart Disease Cancer Depression Diabetes Gastroesophageal reflux disease High Cholesterol High Blood Pressure Thyroid Disease Kidney Disease Liver Disease Osteoarthritis Colon Cancer Pulmonary Disease Stroke Neurological (MS, etc) Autoimmune Siblings Age if living/Age deceased Cause of death Alcoholism Anemia Asthma Heart Disease Cancer Depression Diabetes Gastroesophageal reflux disease High Cholesterol High Blood Pressure Thyroid Disease Kidney Disease Liver Disease Osteoarthritis Colon Cancer Pulmonary Disease Stroke Neurological (MS, etc) Autoimmune Grandparents Age if living/Age deceased Cause of death Alcoholism Anemia Asthma Heart Disease Cancer Depression Diabetes Gastroesophageal reflux disease High Cholesterol High Blood Pressure Thyroid Disease Kidney Disease Liver Disease Osteoarthritis Colon Cancer Pulmonary Disease Stroke Neurological (MS, etc) Autoimmune Children Age if living/Age deceased Cause of death Alcoholism Anemia Asthma Heart Disease Cancer Depression Diabetes Gastroesophageal reflux disease High Cholesterol High Blood Pressure Thyroid Disease Kidney Disease Liver Disease Osteoarthritis Colon Cancer Pulmonary Disease Stroke Neurological (MS, etc) Autoimmune 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? YesNo If so, how much? FeverFatigue Head/Eyes/Ears/Nose/ThroatNoneEar painDizzinessLightheadednessDouble visionVision changeTearingBlind spotsPainNose bleedingSore throatColdsObstructionDischargeNasal congestionHearing lossTrouble falling asleepTrouble staying asleepMouth sores Dental DifficultiesNoneGum bleedingDenturesNeck stiffnessNeck painNeck tendernessMasses in your neckMasses in other areas CardiovascularNoneChest painChest or heart palpitationsPassing out spellsShort of breath on exertionShort of breath lying downSwelling in your legsHypertensionHeart murmursVaricose veinsPhlebitisPain in your legs with walking RespiratoryNoneShortness of breathWheezingCoughRespiratory InfectionsTuberculosis (or exposure to tuberculosis)Fever or night sweats Hematological/LymphaticNoneEasy bruisingExcessive bleedingEnlarged lymph nodes Skin/BreastNoneRashItchingPigmentationDry skinChanges in hair growth/hair lossNail changesBreast lumpsBreast tendernessBreast swellingNipple discharge GastrointestinalNonePainful swallowingIndigestionFood intoleranceAbdominal painHeartburnExcessive gasNauseaVomitingBloody vomitingYellow skinConstipationDiarrheaAbnormal stoolsDark or tarry stoolsBloody stoolsHemorrhoidsRecent changes in bowel habits GenitourinaryNoneUrgencyFrequencyDysuriaFrequent night-time urinationBloody urineUnusual (or change in) color of urineStonesInfectionsHesitancyChange in size of streamDribblingAcute retentionIncontinence EndocrineNoneHeat/cold intoleranceExcessive urination MusculoskeletalNonePainSwellingRedness or heat of muscles or jointsLimitation of motionMuscular weaknessMuscle cramps NeurologicalNoneConvulsionsParalysesNumbness or tingling in hands or legsIncoordinationTremorDifficulties with memory or speechHeadachesPredominant mood "nervousness" (define below) Psychiatric/DepressionNonePrevious psychiatric careTrouble concentratingPoor appetiteFeelings of hopelessness/helplessnessDepressionAnxietyPredominant mood "nervousness" (define)Emotional problemsUnusual perceptionsInsomniaHallucinationsApathyThoughts of hurting yourself or others 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? —Please choose an option—No difficultiesInfrequent difficultiesFrequent difficultiesConstant difficultiesIncapacitating Notes of explanation or clarification on ANY of the General Health Review symptoms above: Female Patients OnlyNot Applicable Age of onset of menses: First date of last period: Irregularity of menstrual cyclePainful, frequent, or excessive bleeding with your periodsPost-menopausal bleedingVaginal dischargePainful intercourse 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 NormalAbnormal Cholesterol test NormalAbnormal Bone Density (DEXA) NormalAbnormal Colon Cancer Screen (colonoscopy, fecal occult blood test) NormalAbnormal Routine Eye Exam NormalAbnormal EKG (electrocardiogram) NormalAbnormal Mammogram NormalAbnormal Pap Smear NormalAbnormal 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: VaginallyC-section? Were you breast fed? YesNo Recurrent health issues as a baby or child? YesNo List: Were you on antibiotics frequently as a child? YesNo Where did you grow up? Please check answers that apply: Please rate your overall health ExcellentGoodFairPoor 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) VegetarianVeganGluten-restrictedGluten-freeHigh ProteinPaleoLow saltLow fatLow carbohydrateNo dairyNo sugar 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 Very ReadyReadyNot ReadyNot Sure I can make time for regular exercise Very ReadyReadyNot ReadyNot Sure I can make time for fun and pleasure Very ReadyReadyNot readyNot sure I am willing to set new priorities Very ReadyReadyNot readyNot sure I am willing to modify my diet Very ReadyReadyNot readyNot sure I am willing to take nutritional supplements Very ReadyReadyNot readyNot sure I will make changes to improve my health Very ReadyReadyNot readyNot sure I am confident that I will follow through and persist Very ReadyReadyNot readyNot sure What challenges do you expect to face when moving towards your healthcare goals? Quality of Life Assessment How do you rate your stress level? HighModerateLowNone How do you cope with your stress? How many hours do you sleep at night? Do you wake feeling refreshed? YesNo Do you consider yourself to be a spiritual person? YesNo Do you meditate? YesNo How happy are you? VeryMostlySomewhatNot at all 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? Your email Your message (optional) Thank you for taking the time to review your health history. Sincerely, The Revive Team Δ