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Name
Age
Address
Date of Birth
/
/
Date
_____
Gender: female___ male ____
City
State
Zip Code
Telephone # (home)
(work)
Email Address __________________________________________________________
Occupation
Hours per week
Retired
Employer
________________________
(Work address)
__________________
Married
Partnership _____Separated
Divorced
Widowed 
Single
Live with: Spouse
Partner
Parents
Children
Friends
Alone
Who referred you ?

What are your most important health problems, in order of importance.
1)
2)
3)
4)
Allergies
Are you hypersensitive or allergic to...
Any drugs?
Any foods?
____________
Environmental substances?
____________
Current Medications
Do you take or use?
Laxatives
Y N
Cortisone
Y N
Tranquilizers Y N
Pain relievers
Y N
Appetite suppressants Y N
Thyroid medication
Y N
Antacids
Smoke
Sleeping pills
Y N
Y N
Y N
Please list any prescription medications, over the counter medications, vitamins
or other supplements you are taking?
1)
4)
2)
3)
5)
6)
GENERAL
lbs.
Weight 1 year ago
When
Weight
Maximum Weight
Height
When during the day is your energy the best?
lbs.
worst?
REVIEW OF SYSTEMS
Y = a condition you have now
P = a condition you have had before
N = never had
Mood Swings?
FOR THE FOLLOWING, PLEASE CIRCLE
MENTAL/EMOTIONAL
Y N P
Anxiety or nervousness?
Y N P
Poor concentration?
Y N P
Memory problems?
Y N P
Difficulty falling asleep
Y N P
Difficulty staying asleep
Y N P
ENDOCRINE
Hypothyroid?
Y N P
Heat or cold intolerance?
Y N P
Hypoglycemia?
Y N P
Diabetes?
Y N P
Fatigue?
Y N P
Seasonal depression?
Y N P
SEX HORMONES
Reduced in sex drive
Y N P
Fertility Challenges:
Y N P
Last Menstrual Period (Women) ___________________________________________
Menstrual related Symptoms: _____________________________________________
History of abnormal PAP:
Y N P Date of Abnormal: ___________________
Other Hormone-related symptoms: ________________________________________
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Vaccinations?
IMMUNE
Y N P
Reactions to vaccinations?
Y N P
Chronic Fatigue Syndrome?
Y N P
Chronic/autoimmunity?
Y N P
Slow wound healing?
Y N P
Chronically swollen glands? Y N P
Rashes?
SKIN
Y N P
Eczema, Hives?
Y N P
Acne, Boils?
Y N P
Y N P
Itching?
HEAD
Headaches?
Y N P
Migraines?
Head injury?
Y N P
When? _________
Y N P
EARS
Earaches?
Y N P
Impaired hearing?
Y N P
Dizziness?
Y N P
Ringing?
Y N P
NOSE AND SINUSES
Frequent colds?
Y N P
Nose Bleeds?
Y N P
Stuffiness?
Y N P
Hay fever?
Y N P
Sinus infections?
Y N P
Loss of smell?
Y N P
MOUTH AND THROAT
Frequent sore throat?
Y N P
Sore tongue/lips?
Y N P
RESPIRATORY
Cough?
Y N P
Wheezing?
Y N P
Asthma?
Y N P
Bronchitis?
Y N P
CARDIOVASCULAR
Heart disease?
Y N P
Palpitations/Fluttering?
Y N P
High/Low Blood Pressure? Y
N P
GASTROINTESTINAL
Heartburn?
Y N P
Belching or passing gas?
Y N P
Change in thirst?
Y N P
Change in appetite?
Y N P
Constipation?
Y N P
Bowel Movements:
3
How often?
Is this a change?
____
Diarrhea?
Y N P
____
URINARY
Increased frequency?
Y N P
Frequency at night?
Y N P
Frequent infections?
Y N P
Vaginal/Prostate infections Y N
P
MUSCULOSKELETAL
Joint pain or stiffness?
Y N P
Arthritis?
Y N P
Muscle spasms or cramps?
Y N P
Injury?
Y N P
HABITS
Do you exercise?
Y N
If yes, what kind?
_
Average 6-8 hrs. sleep?
Y N
Sleep well
Y N
Awaken rested?
Y N
Have a supportive relationship? Y N
Any major traumas?
Y N P
Have a history of abuse?
Y N P
Use recreational drugs?
Y N P
Treated for drug dependence? Y N P
Do you eat 3 meals a day?
Y N P
Do you eat out often?
Y N P
Do you go on diets often?
Y N P
Do you drink coffee?
Y N P
Do you drink black tea?
Y N P
How often? ______
Enjoy your work?
Y N
Take vacations?
Y N
Spend time outside?
Y N
Watch television?
Y N
how many hours? 
Read?
Y N
how many hours? 
Do you use tobacco?
Y N P
Use alcoholic beverages?
Y N P
Treated for alcoholism?
Y N P
Do you add salt?
Y N P
Do you eat refined sugar?
Y N P
Do you drink cola?
Y N
Is there any information about your health you would like to add?
____________
____________________________________________________________________________________________________________
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Your first initial intake will be focused on your health history. Dr. Curtiss is
committed to identifying the cause of your symptoms and improving your
health. At your first follow-up visit she will determine your initial course of care.
Welcome! Dr. Curtiss is happy to help you! If you have any questions, or
concerns, please ask!
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Statement of Consent
Print Name:_____________________________________________________________
RELEASE OF INFORMATION
I authorize Dr. Jennifer Curtiss N.D. to release my medical records and discuss health related
issues to all Portland Family Health providers, case managers, insurance representatives and
lawyers that are involved in my case.
BILLING INFORMATION
To maintain lower rates, insurance is not billed directly. A statement will be provided that you
may send to your insurance company for reimbursement as they allow. I do not fill out forms or
in anyway respond to requests from insurance companies, which may affect
reimbursement. Payment is due at the time of service.
General Rates: The initial visit is $200 for 90 minutes. Follow-up visits are $72, per 30 minutes.
CANCELLATION AND NO SHOW POLICIES
Please give at least 48 hours notice to cancel an appointment. Without this notice, you will
be charged a missed appointment fee of $50, due prior to your next appointment.
ACKNOWLEDGEMENT OF INDEPENDENT PRACTITIONER
Dr. Jennifer Curtiss is an independent practitioner operating under her own licensure and liability
insurance. Her practice is not affiliated with independent practitioners operating at the location of
Portland Family Health. Any questions or concerns regarding your care need to be addressed
with Dr. Jennifer Curtiss.,
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ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I understand that Dr. Jennifer Curtiss will use and disclose health information about me, which
may include written records or spoken words regarding health history, health status, symptoms,
examinations, test results, diagnoses, treatments, procedures, and similar types of health-related
information, in the course of providing care to me. This may be done to make decisions about,
plan for care and treatment, and consult with other health care providers in my course of care. I
have the right to receive a written Notice of Privacy Practices should I request it. I may also
request that some of my health information not be disclosed, and understand that Dr. Jennifer
Curtiss is not required by law to agree to such requests.
The signor certifies that he/she has read, understands, and agrees to the foregoing, and requests
and consents to receive appropriate care from Dr. Jennifer Curtiss N.D.
Patient/Guardian signature________________________________Date___________
If the patient is a minor, I___________________________as the _____parent or ____guardian,
authorize Jennifer Curtiss N.D. to provide treatment.
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