Patient Questionnaire

Emergency Assistance

If this is an emergency, please call:

911 Emergency response
(503)-988-4888 Multnomah County Mental Health Crisis Line.

Patient Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Home address:

City, State, and Zip Code

Health Insurance Member ID

First name

Last name

Health insurance name. Write N/A if uninsured

Insurance member ID and Group #. Write N/A if uninsured

Please upload a picture of the front of your health insurance ID card here:

Add file

Please upload a file

Please upload a picture of the back your of your health insurance ID card here:

Add file

Please upload a file

If you are a dependent under your health insurance plan, please provide us with the full name, and date of birth of the main insured person under your insurance policy.

Profession and employer:

Please list your preferred days and times for your appointment. We will try our best to honor one of your requests.

How did you hear about our clinic?

Can we leave detailed medical messages to the email and phone number provided?

Medical History

Did you have a fever, cough or any flu like symptoms in the last 2 weeks?

Have you been in contact with anyone in the past 2 weeks who had flu like symptoms?

Are you pregnant or breastfeeding?

Yes No

Please describe in detail the reason for your current appointment, including all your current symptoms and when these symptoms have started. Please note that, although we try to provide long visits to all our patients, each appointment should be focused on one health concern. If having several health concerns, please schedule multiple appointments, as we will not be able to go over multiple concerns during a single visit.

Do you have any allergies?

Do you smoke tobacco or have you ever smoked tobacco?

Do you drink alcohol? If you answered yes, how many alcoholic drinks do you drink weekly?

Please list all the medications you are taking and for what conditions. Include the dosage and amounts. Write N/A if not taking any medication.

Please list any supplements you are taking and for what conditions. Include the dosage and amounts. Write N/A if not taking any supplements.

Please let us know if you have any chronic medical conditions and/or about past surgeries or hospitalizations.

*Optional. If having hives, concerning/suspicious moles, skin warts, skin infections, rashes, etc... Please send us a good quality picture of the skin region you are concerned about.

Add file

Please upload a file

Your primary care provider's name: (Write N/A if you do not have a PCP)

Have you been treated by a doctor in the last 12 months?

Yes No

When was the last time you had any bloodwork done? Any abnormals?

Date of your last physical exam

Please describe if having any family history of chronic illness such as cancer, high blood pressure, autoimmune conditions, mental health conditions, heart conditions, or any other chronic health conditions.

Name, address and phone number of your preferred pharmacy:

We will answer to every patient's request for appointments. However, sometimes your email reply may go to your spam folder. Please check your email spam folder if it has been more than 48 hours since you summited your request. Thank you!

Please note that it is patient's responsibility to request their financial insurance information before their appointment. If you need more details about your patient's responsibilities during and after the appointment, (deductibles, co-payments, co-insurances), or if you would like to know our in-network or out-of-network status with your health insurance provider, please contact your insurance provider directly. All self-pay visits, deductibles, co-insurances and co-payments are collected at the time of your appointment. We accept cash, Visa and Mastercard. Our prices for patients that are out-of-network or patients without insurance are posted at our website. If having questions about procedural prices, please contact the clinic directly. Please check this box if you understand and agree with this policy.

Please acknowledge you have read and understood our clinic's policies about last minute cancelations. We schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and staff. If your schedule changes and you cannot keep your appointment, please contact us so we may reschedule you, and accommodate those patients who are waiting for an appointment without suffering any financial loss. As a courtesy to our office as well as to those patients who are waiting to schedule with the physician, please give us at least 24 hours notice. Please notice that extra fees may apply to last minute cancelations and/or no-shows. After three consecutive no-shows to your appointment, our practice may decide to terminate its relationship with you.

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Patient Questionnaire

Emergency Assistance

Patient Information

Health Insurance Member ID

Medical History

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Emergency Assistance

Peach Skin Portland Healthcare