THRIVE Intake Forms Upload

Adult New Patient Forms
Patient Information
Who may we thank for referring you to our clinic?
Name:

First NameLast Name
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Mailing Address:

Address

Street Address Line 2

CityState

Zip
Cell Phone:
Format: (000) 000-0000.
Home Phone:
Format: (000) 000-0000.
Email Address:
example@example.com
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age:
Occupation:
Employer/School:
Height:
Weight:
Gender:
Marital Status:

Other
Spouse's Name:
Number of Children and Ages:
Emergency Contact and Relationship:
Emergency Contact Phone Number:
Format: (000) 000-0000.
Medical Data and History
Purpose of this visit or concern:
When did you first start experiencing these symptoms, if any?
Is there anything that makes this problem worse?
Have you done anything that gives you relief?
Have you ever received chiropractic care?
If you have been previously adjusted, when was your last adjustment?
Have you seen other health care providers for this condition? If so, who?
How severe are your symptoms on a scale of 1-10?
What type of pain are you experiencing? (Please check all that apply)

Other
Are these symptoms the result of ANY type of accident?
If your symptoms are the result of an accident, please explain:
Please circle areas on the image below where you have discomfort or pain:
Activities or movements that are painful to perform:

Other
Are you currently pregnant, breastfeeding, or nursing?
Number of past pregnancies:
List all past motor vehicle accidents (Please include dates):
List any injuries / traumas as a child or adult (Please include dates):
List any broken bones or dislocations (Please include dates):
List all past surgeries (Please include dates):
If you are currently taking any medications please list them below:
If you are currently taking any supplements please list them below:
Health Conditions
Please check the box beside any condition that you have or have had in the past:

Other
Authorization of Care

The statements made on this form are true, complete, and accurate to the best of my knowledge and I agree to allow this office to examine me for further evaluation.
SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Adult New Patient Forms

Patient Information

Medical Data and History

Health Conditions