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TNH Health History Questionnaire
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Check as many that apply to you about your reason for visiting us today:
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If other, please describe here:
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If injury occurred, when?
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Describe:
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Any other type of accident, trauma, or injury:
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Neurological problem or disease: (Please explain & include any prior diagnoses)
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Diagnostics: (Please list previous diagnostic tests given for current complaints)
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Context of Your Pain Symptoms
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Event(s) surrounding the onset of symptoms: (Include date)
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Pain Intensity Today compared to the onset:
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Current Level of Pain/Symptomatology (0 being none, to 10 being worst pain possible)
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Pain/Symptomatology Diagram
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Mobile users can interact with diagram directly, PC/MAC users must screenshot to interact and separately send as a message.
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Brain Health Rank
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How well do you think your brain is functioning?
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Have you seen anyone else for this condition?
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If yes, who?
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Have you lost work days because of this condition?
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If yes, how many?
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How long has this problem been present?
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How many, exactly?
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What do you think is causing your present condition?
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Indicate any other symptoms you think may be important.
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What are your 3 greatest concerns about your present state of health?
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1.
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2.
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3.
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Expectations
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What are you hoping to gain from your visit to Thrive? Check % relief/increase in function that would make it feel worthwhile?
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What is the most important thing we can do for you?
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Personal Health History - Please answer the following questions as completely as possible.
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Do you have a:
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If yes on any, please explain
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List all operations and surgeries you may have had, with dates (month/year)
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List any major illness you have had, with dates (month/year)
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Have you had any recent infections, colds, or flu?
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If yes, when?
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Have you suffered a Head Injury or Concussion?
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Did you lose consciousness? How long?
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Have you been diagnosed with a tumor, cancer, or neoplasia?
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If yes, what condition and when?
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Have you been diagnosed with diabetes?
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If yes, when?
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Have you been diagnosed with a heart condition, a blood vessel condition (like arteriosclerosis), or high blood pressure?
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If yes, what condition and when?
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Have you ever had a stroke or heart attack?
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If yes, when?
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Have you ever had a spinal cord injury?
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If yes, when?
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Have you ever had surgery on your neck?
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If yes, when?
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Does anyone in your biological family (parent, grandparent, sibling, or child) have a history of:
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Heart disease, stroke, or diabetes?
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If yes, Explain
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Psychiatric diseases like depression, anxiety, schizophrenia, etc?
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If yes, Explain
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Neuropathies (nerve disease) or myopathies (muscle disease)?
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If yes, Explain
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Cancer?
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If yes, Explain
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Back or neck pain?
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If yes, Explain
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Any other known conditions?
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If yes, Explain
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The following questions help us determine levels of stress. Please answer as completely as possible.
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Please indicate your familial status
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How many children do you have?
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Other:
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Do you have a second job?
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How many hours a week?
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Describe your work environment:
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Describe your home life:
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What is your highest level of education?
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What are your hobbies?
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Social History - Please answer as completely as possible.
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Quality of Life Rank
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Has quality of life changed?
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If yes, Explain
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Do you exercise?
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What type and how often?
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Do you currently use any tobacco products?
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What kind, how often, and how long?
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Have you used any tobacco products in the past?
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What kind, how long, and when did you quit?
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Do you drink alcoholic beverages?
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What kind and how many a week?
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Have you had issues with alcohol in the past?
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How long ago and for how long?
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Do you drink caffeinated beverages?
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What kind and how many a day?
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Do you currently use recreational drugs?
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What type, how often, and how long?
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Have you used recreational drugs in the past?
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What kind, how often, and how long?
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Are you sexually active?
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Have you ever been diagnosed with an STD or VD?
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Please list diagnosis:
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Do you have any special dietary restrictions?
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What type?
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Do you currently see a chiropractor?
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Who?
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When did you last see a chiropractor?
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Quality of Sleep
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Please indicate where you rate your current quality of sleep
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Can you fall asleep?
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For how long?
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Nightmares/Vivid dreams?
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Difficult to stay asleep?
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How many times do you wake up?
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Night sweats?
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Restless leg at night?
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Headache
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Please indicate where you would rate your current headache pain.
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Where do you feel the head pain?
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Does the pain start at the neck and go up?
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Have you identified triggers of the headache?
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Please list them here:
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How often are the headaches?
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What makes it better?
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Quality of headache?
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Other:
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Balance/Vestibular Health History - Please answer the following if applicable to your experience.
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Please describe your complaint in your own words w/o using the word “dizzy.”
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Check all that apply to balance complaint here.
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If "other", describe briefly here:
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Have you seen anyone else for this complaint?
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If "yes" answered above, who have you seen.
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If "yes," what treatments have you received?
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If "yes," what were the outcomes of treatment?
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Have you ever experienced this type of problem before?
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If "yes" answered, when and how many times?
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Did you see anyone previously? Who?
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What treatments did you receive?
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If "yes," what were the outcomes of treatment?
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Do you ever experience the following sensations?
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"Spinning in circles"?
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If, "Yes," describe the direction
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"Falling to one side"?
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If, "Yes," describe the direction
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The world is spinning around you.
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If, "Yes," describe the direction
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You are spinning around the world.
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If, "Yes," describe the direction
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Any falls due to these symptoms?
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If you have fallen, have you been injured?
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If injured in fall indicated above, explain here.
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Answer the following about a typical "dizzy" spell you may be experiencing:
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When did you notice your first dizzy spell (i.e. date)?
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Describe where you were and how your first dizzy spell came on:
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Any Rx's or OTC's or other meds taken before symptoms came on?
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If yes, describe
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Does anything trigger the onset of your dizzy spells?
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If yes, explain
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Did you have a recent cold or flu prior to your recent dizzy spells?
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Do these dizzy spells come in attacks?
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How long do these dizzy spells last?
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What time of day do these dizzy spells occur?
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Completely free of dizziness between attacks?
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Does it occur mainly when you sit up or stand up too quickly?
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What positions are you mainly dizzy in?
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Are you dizzy even when lying down?
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Do you have difficulty getting into bed?
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Any remaining information regarding your balance that you would like us to know?
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Review of Systems & Medical History
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Does anything trigger your symptoms such as:
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Other:
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Do your symptoms get worse with physical or mental activity?
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If yes, Explain
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Are you currently experiencing any of the following symptoms, now or recently?
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Please indicate any of the following symptoms you are currently experiencing, now or recently:
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Have you noticed any of the following?
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Please list any & all applicable conditions below this diagram for non-mobile users who cannot interact directly with the chart.
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Please list all conditions/symptoms here, marking them individually with (present) and (past) following each:
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Females only section: Is there any possibility that you are currently pregnant?
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What was the date of your last menstrual period?
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Closing information
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Are there any other concerns or interests you have about your health that you would like us to address?
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Patient Authorization
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Patient's (or guardian's) initials:
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Date:
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Initials of translator or person assisting you (if any)::
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Date:
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Printed name:
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