1. General Information: Last Name: _____________ First Name: _________________ Middle Initial: ___ Date: _________ Date of Birth: ____/ ____/ _____ Age: ____ Sex: [ ] M [ ] F Social Security#: _____-____-_____Address: ____________________________ City: ____________ State: ___ Zip Code: ________Cell Phone#: (_____) ______-__________ Home Phone#: (_____) ______-__________ Email: ___________________ Primary Physician: _________________ Location: _____________Marital Status: [ ] Married [ ] Single [ ] Widowed [ ] Divorced [ ] Separated [ ] PartneredRetired? [ ] Yes [ ] No Disabled? [ ] Yes [ ] No Occupation: _________________________Height: _______feet _____inches Weight: _______ lbs.

4. Assignment of Benefits I authorize the use of my signature on all insurance submissions for the purpose of obtaining payment and authorize Dr. Stokes access to my past and present healthcare information and disclosure of such information to my insurance company for the purpose of obtaining payment.

Your Signature: _______________________________________ Dated: _____/_____/ 2017

Advanced Pain Solutions Dr. Stephen Stokes BSc,DC,FIAMA

13730 Cypress Terrace Circle Unit 401Fort Myers, Florida 33907

(239) 275-7575 Ph (239) 275-7035 Fax Since 2001

2. Due to New Healthcare Reform Guidelines, we are legally required to obtain the following information to get a better sense of the overall diversity of our patient population and have a better understanding of our practice and patient needs. This confidential information will assist us in improving the quality of our care you receive in our office and is required by law.Primary Language: [ ] English [ ] German [ ] Italian [ ] Spanish [ ] French [ ] Mandarian [ ] Cantonese [ ] Tagalog [ ] Japanese [ ] Chinese [ ] Other ___________________

Race: [ ] White [ ] Asian [ ] American Indian/ Alaska Native [ ] Black/ African American [ ] Hawaiian/Pacific Islander [ ] More than one Race [ ] Unreported/Refuse to Report

Ethnicity: [ ] Hispanic or Latino [ ] Not Hispanic or Latino [ ] Unreported/Refuse to Report

Your preferred method of contact from our office? [ ] Home Phone [ ] Cell [ ] Email [ ] Text Would you like online access to your medical records (email needed)? [ ] No [ ] Yes Email address: __________________@ ________________

3. Method of PaymentWe accept credit cards, personal check and cash for services rendered. We also accept Medicare and some private insurances. We will verify your coverage and all costs prior to starting any treatment or accepting you as a patient. [ ] I have medical insurance [ ] I am self pay patient

5. PRESCRIPTION MEDICATIONS

Medication:i.e Lipitor

# of Refills Quantity: Strength:i.e. 10 mgs

Dose Form:i.e. Capsule

Frequency:i.e. 1 per day

Advanced Pain Solutions Dr. Stephen Stokes BSc,DC,FIAMA

13730 Cypress Terrace Circle Unit 401Fort Myers, Florida 33907

(239) 275-7575 Ph (239) 275-7035 Fax Since 2001

[ ] Check here if you are not taking any prescription medications[ ] Check here if you are providing a separate list of medications

6. DRUG ALLERGIES[ ] Check here if you are not allergic to any medications.

Name of Drug: i.e. Penicillin Symptom: i.e. Headaches

8. ORTHOTIC PRESCRIPTIONHave you received a medical prescription for a Back Brace or have you purchased a back brace either directly from a store, by phone or over the internet in the last 5 years?[ ] Yes [ ] No [ ] I am not sure : ___________________________________________________

7. OTHER ALLERGIES (latex, peanuts etc…)[ ] Check here if you are not allergic to any other substances_____________________________________________________________________________

Advanced Pain Solutions Dr. Stephen Stokes BSc,DC,FIAMA

13730 Cypress Terrace Circle Unit 401Fort Myers, Florida 33907

(239) 275-7575 Ph (239) 275-7035 Fax Since 2001

9. MEDICAL HEALTH HISTORY1. Rate your overall health? [ ] Excellent [ ] Very Good [ ] Good [ ] Fair [ ] Poor 2. Indicate regular exercise you perform: [ ] Strenuous [ ] Moderate [ ] Light [ ] None3. Smoking Status: [ ] Smoke everyday [ ] Smoke some days [ ] Former smoker [ ] Never4. Alcohol use: [ ] +9 drinks a week [ ] 5-8 drinks a week [ ] 1-4 drinks a week [ ] No alcohol5. Family history includes: [ ] Rheumatoid [ ] Heart [ ] Cancer [ ] Diabetes [ ] Lupus [ ] ALS6. Are your parents deceased? [ ] No [ ] Yes Cause of death, Father ________ Mother ________

10. CURRENT/ PAST MEDICAL PROBLEMSPast Current[ ] [ ] Headaches [ ] [ ] Neck Pain[ ] [ ] Upper Back Pain[ ] [ ] Mid Back Pain[ ] [ ] Low Back Pain[ ] [ ] Shoulder Pain[ ] [ ] Elbow Pain[ ] [ ] Wrist Pain[ ] [ ] Hand Pain[ ] [ ] Hip Pain[ ] [ ] Upper Leg Pain[ ] [ ] Knee Pain[ ] [ ] Lower Leg Pain[ ] [ ] Ankle/ Foot Pain[ ] [ ] Jaw Pain[ ] [ ] Joint Pain/ Stiffness[ ] [ ] Arthritis[ ] [ ] Rheumatoid Arthritis

Past Current[ ] [ ] Cancer[ ] [ ] Tumor[ ] [ ] Asthma[ ] [ ] Sinusitis[ ] [ ] Hypertension[ ] [ ] Heart Attack[ ] [ ] Chest Pain[ ] [ ] Stroke[ ] [ ] Angina[ ] [ ] Kidney Stones[ ] [ ] Kidney Disease[ ] [ ] Bladder Infection[ ] [ ] Painful Urination[ ] [ ] Loss of Bladder Control[ ] [ ] Prostate Problems[ ] [ ] Weight Gain[ ] [ ] Loss Appetite[ ] [ ] Abdominal Pain

Past Current[ ] [ ] Ulcer[ ] [ ] Hepatitis[ ] [ ] Liver/ Gallbladder Pain[ ] [ ] General Fatigue[ ] [ ] Muscular Incoordination[ ] [ ] Visual Disturbance[ ] [ ] Dizziness[ ] [ ] Diabetes[ ] [ ] Excessive Thirst[ ] [ ] Frequent Urination[ ] [ ] Tobacco Use[ ] [ ] Drug/ Alcohol Dependence[ ] [ ] Allergies[ ] [ ] Depression[ ] [ ] Lupus[ ] [ ] Epilepsy[ ] [ ] Dermatitis/ Eczema[ ] [ ] HIV/ AIDS

11. PAST SURGERIES/ HOSPITALIZATIONS [ ] Check here if you have never had a surgery________________________________________________________________________________________________________________________________________________________________________

12. VITAMINS/ SUPPLEMENTS [ ] Check if you are not taking any Vitamins or Supplements________________________________________________________________________________________________________________________________________________________________________

13. CONTAGIOUS DISEASEAre you currently suffering from any disease that maybe considered contagious by the department of health, including Herpes, Hepatitis, Influenza, Bacterial or Viral Infection, Auto Immune Disorder (Lyme, Cancer, Various Skin Disorders) [ ] No [ ] Yes - This will be reviewed with the doctor if answered Yes.

Advanced Pain Solutions Dr. Stephen Stokes BSc,DC,FIAMA

13730 Cypress Terrace Circle Unit 401Fort Myers, Florida 33907

(239) 275-7575 Ph (239) 275-7035 Fax Since 2001

14. What concerns you most about your condition? (check all that apply) [ ] Not getting better [ ] May need surgery [ ] Have to take medications for life [ ] Lose ability to function, exercise or enjoy life [ ] It is a hopeless situation [ ] Will have to give up activities I enjoy [ ] Become a burden [ ] Financial expense of future care [ ] It could be very serious [ ] It is not going away [ ] Affecting leisure activities [ ] Affecting work [ ] It is getting worse [ ] Affecting sleep [ ] Affecting relationships

1. Using your ink pen, mark the Location of your main chief complaint on the diagram below:14. CHIEF COMPLAINT

2. How often do you experience symptoms?

: 3 Units (|) Mild, (+) Moderate, (x) Severe

: 3 Units (T) Tender, (S) Spasm, (E) Edema

Increase: [ ] Cervical [ ] Lumbar: _________Decrease: [ ] Cervical [ ] Lumbar: _________

Supports[ ] Lumbar Brace[ ] Cervical Brace[ ] Thoracic Brace

Exercises/ Stretches[ ] Mobilization[ ] Reeducation[ ] Strengthening

Instructions Given To Patient Today: Interval: __________________________Duration: _________________________Therapist: ________________________Doctor Reviewed: ___________________

Plan Notes: _____________________________________________________________________________________________

[ ] Functional Index [ ] PGIC Completed [ ] Examination Today [ ] X-Rays Taken ______________________

Location: [ ] 98940 CMT 1-2 Regions 1. ______ 2. ______ [ ] 98941 CMT 3-4 Regions 1. ______ 2. ______ 3. _____ 4. _____

ADJUSTMENT NOTES: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________

What have you done to aggravate?: ___________________________________________________________________________When does pain reduce? _______________________________Where does the pain radiate to?: ________________________Associated symptoms?: ________________________________How was last treatment?: _______________________________

What percentage of the waking day are you in Pain?0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100%

3. How would you describe your symptoms?[ ] Sharp[ ] Dull[ ] Diffuse[ ] Achy

[ ] Burning[ ] Shooting[ ] Stiff[ ] Numb

[ ] Tingly[ ] Sharp with motion[ ] Shooting with motion[ ] Electric like with motion

4. How are your symptoms changing? [ ] Getting worse [ ] Staying the same [ ] Getting better5. What is your highest Pain Level: No Pain 0 1 2 3 4 5 6 7 8 9 10 - Worst Pain6. Interfered with your work? [ ] No [ ] Slightly [ ] Moderately [ ] Substantially [ ] Extremely7. Interfered socially? [ ] No [ ] Slightly [ ] Moderately [ ] Substantially [ ] Extremely8. Who have you seen for this condition? [ ] No one [ ] check all you have seen below [ ] Chiropractor[ ] ER Doctor

[ ] Orthopedist[ ] Physical Therapist

[ ] Massage Therapist[ ] Neurologist

[ ] Primary Doctor[ ] Pain Management

9. How long have you had this problem? __ [ ] weeks [ ] months [ ] years [ ] Too long to remember10. How do you think it began? (Explain): _____________________________________________ _______________________________________________________________________________11. Are you considering surgery? [ ] Yes [ ] No [ ] Maybe12. What aggravates the condition (check all that apply)?[ ] Sitting [ ] Standing [ ] Walking [ ] Getting up from chair/ bed [ ] Exercising [ ] Other: _____________________________________________________________________

13. What has helped alleviate the condition (check all that apply)?[ ] NSAIDS [ ] Pain Medicine [ ] Ice [ ] Heat [ ] Massage [ ] Resting [ ] Sitting [ ] Standing[ ] Walking [ ] Stretching [ ] Swimming [ ] Lying on stomach [ ] Lying on back [ ] Bracing[ ] Other: _____________________________________________________________________

[ ] Constantly (76-100% of waking day)[ ] Frequently (51-75% of waking day)[ ] Occasionally (26-50% of waking day)[ ] Intermittently (1-25% of the waking day)

[ ] Acupuncture[ ] Gym Trainer