Divine Medicine NW Greenbrier Parkway, Suite 100 Beaverton, Oregon P F
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1 Divine Medicine NW Greenbrier Parkway, Suite 100 Beaverton, Oregon P F Patient Demographic Information: Patient Name Street Address Last Name First Name Middle Initial City State Zip Code Home Phone Work Phone Cell Phone You can leave messages pertaining to my health at my: Home Work Cell Birth Date Patient s SS # Gender M F Age Occupation Full-time Part-Time Emergency Contact Contact # How did you hear about us? Primary Health Concerns: Goals for Visit: Allergies: Immunizations in past 10 years: Hospitalizations & Surgeries Dates Other physicians health care providers:
2 List all medications quantity List all supplements quantity Do you use alcohol? Yes No How much how often? Do you use tobacco? Yes No How much how often? Do you drink coffee? Yes No How much how often? Do you exercise? Yes No How much how often? How much water do you drink each day? How many hours of sleep do you get night? Rate your stress level: None Low Moderate High Unbearable Is the a Faith or Spiritual Practice that helps with your stress? Weight History Current height Max weight Do you have any specific cravings? What diets have you tried? Are you an emotional eater? Current weight Min weight Symptoms please circle Y for conditions you have now, N for those you ve never had and P for a condition you have had in the past. Childhood Illnesses Scarlet Fever Y N P Diphtheria Y N P Rheumatic Fever Y N P Mumps Y N P Measles Y N P German Measles Y N P General Fatigue Y N P Brain Fog Y N P Insomnia Y N P Poor concentration Y N P Mood swings Y N P Chronic fatigue synd. Y N P Fibromyalgia Y N P Endocrine Hypothyroid Y N P Hyperthyroid Y N P Heat Cold Intol. Y N P Hypoglycemia Y N P Diabetes Y N P Excessive thirst Y N P Weight Gain Y N P Weight Loss Y N P Vaginal Dryness Y N P Hot Flashes Y N P Night Sweats Y N P PMS Y N P Low libido Y N P Diff. achiev. orgasm Y N P Seasonal depression Y N P Mental Emotional Anxiety Y N P Panic Attacks Y N P Depression Y N P Attempted Suicide Y N P His. of abuse Y N P His. of addiction Y N P
3 Immune Chronic infections Y N P Slow wound healing Y N P Swollen glands Y N P Allergies Y N P Autoimmune disease Y N P Mononucleosis Y N P Blood Peripheral Vascular Easy bruising Y N P Varicose veins Y N P Cold hands feet Y N P Deep leg pain Y N P Anemia Y N P Thrombophlebitis Y N P Neurologic Seizures Y N P Paralysis Y N P Muscle weakness Y N P Numbness or tingling Y N P Loss of memory Y N P Vertigo or dizziness Y N P Loss of balance Y N P Restless Leg Syn. Y N P Sciatica Musculoskeletal Joint pain or stiffness Y N P Broken bones Y N P Weakness Y N P Muscle spasms Y N P Arthritis Y N P Back pain Y N P Skin Rashes Y N P Acne Y N P Itching Y N P Color changes Y N P Vitiligo Y N P Lumps Y N P Hair loss Y N P Eczema Y N P Psoriasis Y N P Head Headaches Y N P Migraines Y N P Head injury Y N P Jaw TMJ problems Y N P Scalp hair loss Eyes Glasses or contacts Y N P Blurriness Y N P Eye pain strain Y N P Double vision Y N P Tearing or dryness Y N P Cataracts Y N P Glaucoma Y N P Spots or floaters Y N P Color blindness Y N P Ears Impaired hearing Y N P Ringing Y N P Ear infections Y N P Dizziness Y N P Hearing loss Y N P Nose and Sinuses Frequent colds Y N P Nose bleeds Y N P Stuffy congestion Y N P Hay fever Y N P Freq. sinus infections Y N P Loss of smell Y N P Nasal polyps Y N P Deviated septum Y N P Mouth and Throat Freq. sore throat Y N P Enlarged tonsils Y N P Difficulty swallowing Y N P Gum disease Y N P Sore tongue lips Y N P Dental cavities Y N P Teeth grinding Y N P Dry mouth Y N P Copious saliva Y N P Neck Lumps Y N P Goiter Y N P Swollen glands Y N P Pain or stiffness Y N P Respiratory Cough Y N P Sputum Y N P Coughing up blood Y N P Wheezing Y N P Asthma Y N P Bronchitis Y N P Shortness of breath Y N P Pleurisy Y N P Emphysema Y N P Difficulty breathing Y N P Pain with breathing Y N P Pneumonia Y N P Tuberculosis Y N P Cardiovascular Heart disease Y N P Angina Y N P Heart murmur Y N P High blood pressure Y N P Low blood pressure Y N P Blood clots Y N P Palpitations Y N P Arrhythmias Y N P Phlebitis Y N P Rheumatic fever Y N P Swelling in ankles Y N P Chest pain Y N P Elev. Cholesterol Y N P Elev. Triglycerides Y N P Comments:
4 Gastrointestinal Trouble swallowing Y N P Heartburn Y N P Change in appetite Y N P Nausea Y N P Vomiting Y N P Vomiting blood Y N P Blood in stool Y N P Abdominal cramps Y N P Diarrhea Y N P Constipation Y N P Bloating gas Y N P Gall bladder disease Y N P Black stools Y N P Ulcer Y N P Jaundice Y N P Liver disease Y N P Hemmorhoids Y N P Bowel movday Urinary Pain on urination Y N P Increased frequency Y N P Incontinence Y N P Frequency at night Y N P Frequent infections Y N P Kidney stones Y N P Female Reproductive Breast health Age of first menses Length of cycle Regular cycles Y N P Age of last menses Duration of menses Midcycle spotting? Y N P Pain with menses Y N P Clotting Y N P Heavy flow Y N P Light flow Y N P PMS Y N P Discharge Y N P Pain during Y N P Endometriosis Y N P Ovarian cysts Y N P intercourse Hormonal birth Y N P If current, brand: control # of pregnancies # of live births # of miscarriages Abnormal Pap Y N P HPV Y N P Chlamydia Y N P Gonorrhea Y N P Herpes Y N P Condyloma (warts) Y N P Syphilis Y N P Currently sexually active? Breast pain tender Y N P Breast lumps Y N P Nipple discharge Y N P Breast feeding Y N P Mastitis Y N P Breast cancer Y N P Male Reproduction Testicular masses Y N P Hernias Y N P Prostate enlarge. Y N P Testicular pain Y N P Testicular cancer Y N P Prostate cancer Y N P Prem. Ejaculation Y N P Erectile dysfunction Y N P Sores lesions Y N P Discharge Y N P HPV Y N P Chlamydia Y N P Gonorrhea Y N P Herpes Y N P Condyloma (warts) Y N P Syphilis Y N P Currently sexually active? Family History (MGM = maternal grandmother, PGF = paternal grandfather etc) Asthma Allergies Cancer (type?) Diabetes Heart Disease Stroke Hepatitis High Blood Pressure Thyroid Disorder Other Mother Father Sibling MGM MGF PGM PGF
5 Consent to Treat I have been informed and understand that: 1. Any treatment or advice provided to me as a patient of Dr. Chris D. Meletis, is not mutually exclusive from any treatment or advice that I may be receiving now or in the future, from another health care provider 2. I am at liberty to seek or continue medical care from a physician, surgeon, or other health care provider and no physician or staff member is recommending that I refrain from seeking or following the advice of another licensed health care provider. 3. The treatment and therapies provided or recommended by this clinic may be different from those usually offered by another licensed health care provider. Statement of Financial Responsibility: I understand and agree to the following: Payments for services rendered are my responsibility as the patient or the patient s responsible party. I am responsible for paying for all services, including lab tests, rendered at the time of service. Insurance Billing If insurance is being billed for services rendered, I understand and agree to the following: I authorize Dr. Chris D. Meletis, to release pertinent medical records related to billing directly to my insurance carrier. This release applies to support the insurance billing process only. I understand that it is my responsibility to provide adequate insurance billing information including a copy of a valid insurance card. I am responsible for any and all charges that my insurance company will not cover.
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(PLEASE CIRCLE YES ANSWERS ONLY) Childhood Illnesses Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N Mumps Y N Measles Y N German Measles Y N Hospitalizations and Surgery What hospitalizations or
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