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