ADULT PRACTICE MEMBER QUESTIONNAIRE

THRIVAL MO!lE

First Name: Last Name:

Names & Ages of Children (if any):

Spouse's Name (if married):

Mailing Address:

City, State, Zip:

Email: Cell Phone:

Emergency Contact: Emergency Relation:

How did you hear about us?

Please note any significant family medical history:

CURRENT HEALTH

What health concerns bring you into our office?:

Date:

D.O.B:

Employer:

Occupation:

Text Reminders: Q Yes O No

Other Phone:

Emergency Phone:

Please indicate where you are experiencing pain or d iscomfort.

1-------------------------------------tX- Current condition 0 - Past condition

Have you received care for this problem before? 0 Yes O No - If yes, please explain:

When did the condition(s) first begin?

How did the problem start? Q Suddenly Q Gradually O Post-lnjury

Is this condition: 0 Getting Worse O Improving O lntermittent O Constant O Unsure

What makes the problem better?

What makes the problem worse?

YOUR HEALTH GOALS Your top three health goals:

1_ Intermediate:

2. Short-term:

3. Long-term:

@HRIVAL MODE I 1815 CENTRAL PARK DR. STEAMBOAT SPRINGS, CO 80487 I 970.717.0012 I THRIVALMODE.COM