SS/HIC/Patient ID # _

Last Name

First Name Miadle Initial

Zip _

E-mail _

Sex OM OF Age __

Birthdate _

o Married o Widowed

D Divorced

D Single D Minor

o Separated D Partnered for years

Occupation _

Patient Employer/School _

Employer/School Address _

Employer/School Phone ( ) __

Spouse's Name _

Best time and place to reach you _IN CASE OF EMERGENCY, CPNTACT

Home phone (__ ) _

INSURANCE

Relationship to Patient

Who is responsible for this account? _

Relationship to Patient __

Insurance Co. _

Group# _

Is patient covered by additional insurance? 0 Yes 0 No

Subscriber's Name _

SS# _Birthdate _

Relationship to Patient _

Insurance Co. _

Group# _

ASSIGNMENT AND RELEASEI certify that I, and/or my dependent(s), have insurance coverage with

-------.===c::7'C===c::-::-rc:==-==-::-;----- and assign directly toName of Insurance Company(ies)

Dr. all insurance benefits,if any, otherwise payable to me for services rendered. I understand that I amfinancially responsible for all charges whether or not paid by insurance. Iauthorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclosesuch information to the above-named Insurance Company(ies) and their agentsfor the purpose of obtaining payment for services and determining insurancebenefits or the benefits payable for related services. This consent will end whenmy current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal Representative

Date

ACCIDENT INFORMATION

Is condition due to an accident? DYes D No

Drue _

Type of accident 0 Auto 0Work 0 Home 0Other

To whom have you made a report of your accident?o Auto Insurance 0 Employer 0Worker Compo 0Other

Attorney Name (if applicable)

When did your symptoms appear? _

.(l1li--:" Is this condition getting progressively worse? 0 Yes 0 No 0 Unknown

Mark an X on the picture where you continue to have pain, numbness, or tingling.

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) _

Type of pain: D Sharp D Dull D Throbbing D Numbness 0 AchingD Burning D Tingling 0 Cramps 0 Stiffness 0 Swelling

o Shootingo Other

How often do you have this pain? _

Is it constant or does it come and go? _

Does it interfere with your 0 Work 0 Sleep D Daily Routine D Recreation

HEALTH HISTORY

What treatment have you already received for your condition? 0 Medications o Surgery o Physical Therapy

o Chiropractic Services o None o Other

Name and address of other doctor(s) who have treated you for your condition

Date of Last: Physical Exam Spinal X-Ray Blood Test

Spinal Exam Chest X-Ray Urine Test

Dental X-Ray MRI, CT-Scan, Bone Scan

Place a mark on "Yes" or "No" to indicate if you have had any of the following:AIDS/HIV DYes DNo Chicken Pox DYes DNo Liver Disease DYes DNo RheumatoidArthritis DYes DNo

Alcoholism DYes DNo Diabetes DYes DNo Measles DYes DNo Rheumatic Fever DYes DNo

Allergy Shots DYes DNo Emphysema DYes o No MigraineHeadaches 0 Yes DNo Scarlet Fever DYes DNo

Anemia DYes o No Epilepsy DYes DNo Miscarriage DYes DNo Stroke DYes DNo

Anorexia DYes DNo Fractures DYes DNo Mononucleosis DYes DNo Suicide Attempt DYes DNo

Appendicitis DYes DNo Glaucoma DYes DNo Multiple Sclerosis DYes DNo Thyroid Problems DYes DNo

Arthritis DYes DNo Goiter DYes DNo Mumps DYes DNo Tonsillitis DYes DNo

Asthma DYes DNo Gonorrhea DYes DNo Osteoporosis DYes DNo Tuberculosis DYes DNo

Bleeding Disorders DYes DNo Gout DYes DNo Pacemaker DYes DNo Tumors, Growths DYes DNo

Breast Lump DYes DNo Heart Disease DYes DNo Parkinson's Disease 0 Yes DNo Typhoid Fever DYes DNo

Bronchitis DYes DNo Hepatitis DYes DNo Pinched Nerve DYes DNo Ulcers DYes DNo

Bulimia DYes DNo Hernia DYes DNo Pneumonia DYes DNo Vaginal Infections DYes DNo

Cancer DYes DNo Herniated Disk DYes DNo Polio DYes DNo Venereal Disease DYes DNo

Cataracts DYes DNo Herpes DYes DNo Prostate Problem DYes DNo Whooping Cough DYes DNo

Chemical High Cholesterol DYes DNo Prosthesis DYes DNo Other

Dependency DYes DNo . Kidney Disease DYes DNo PsychiatricCare DYes DNo

EXERCISE WORKACTIVITY HABITSo None o Sitting o Smoking Packs/Day

D Moderate D Standing DAlcohol Drinks/Week

o Daily o Light Labor o Coffee/Caffeine Drinks Cups/Day

D Heavy o Heavy Labor o High Stress Level Reason ,

Are you pregnant? DYes DNo Due Date

Injuries/Surgeries you have had Description Date

Falls '":

Head Injuries

Broken Bones

Dislocations

Surgeries

MEDICATIONS ALLERGIES VITAMINS/HERBS/MINERALS

Pharmacy Name _

Pharmacy Phone (__ ) _

CURRENT COMPLAINT HISTORY(PATIENT)

Patient Name: --------------------------------------------------- Date: --~~

Please check all boxes that appll' to your condition and fill in the spaces that describe your present complaint(s). Also, theinformation you provide concerning past symptoms will help in assisting the doctor to better understand your presentcomplaints and total health picture.

Please list your present complaint(s) and mark your level of pain today for each complaint - If you have more than one area ofcomplaint list them in order of most severe to least severe.

1. Duration - (How Long I Date) # of Previous Episodes(Please circle one.) (No pain) o 2 3 4 5 6 7 8 ':) I () (Worst pain imaginable)

2. Duration - (How Long / Date) # of Previous Episodes(Please circle one) (No pain) () 2 3 4 5 6 7 8 9 1 0 (Worst painimaginable)

3 Duration - (How Long / Date) # of Previous Episodes(Please circle one) (No pain) 0 2:1 4 5 6 7 8 ') 10 (Worst pain imaginable)

Has anyone treated you for this episode') DYes DNo If yes, by whom') _

How did your symptoms begin?Dlnunediately after a specific incident DAfter multiple Incidents DGradually developed over time DOther ~

What makes your symptoms better?DNothing DLying down DStanding DSitting DMovement/Exercise DOther __ ~~~~~~~~~~~~ __

What makes your symptoms worse?DN~~D~~d~nDS~d~DSi~tt:~~g~D:M=o~v:~=~:t~ffi=x=·e~~=i:se~D=O:ili:e:r~~~~~~~~~~~~~~=

Are your symptoms?ODecrt:asingDNot Changing

oIncreasingDOther _

Description of pain or symptoms.DSharp DShootingoDull DBumingDAche DNumbDWeaknessoThrobbing

DTinglingDOther~_~ __

Does your pain move or radiate?DYes DNo Where ~~~~_

Check the best and worse times of the day foryour pain:

WorseDFirst AwakeDMomingDAftemoonOEvenillgDNighttimeDOther

oFirst AwakeDMomingDAftemoonOEveningDNighttimeDOther

SHOW US YOUR PAINUSE THE LETTERS BELOW TO INDICATE THE TYPE

AND LOCATION OF YOUR SYMPTOMS TODAY

KEY A = ACHES'" STABBING

B=BURNINGX '" STIFFNESS

N '" NUMBNESS P = PINS & NEEDLEST '" THROBBING 0 '" OTHER

LEFT RIGHT

\

Frequency of pain or symptomsDConstant (76 - 100%)DFrequent (51 - 75%)DOccasional (26 - 50%)Dlntermittent (25% or less)

How many days out of an avet"age week are you 111 pain? (Please circle one) 1 2 3 4 5 6 7

How much time during the day are you in pain?Oless than I hour 0 I to 6 hours 06 to 12 hours 012 to 18 hours 018 to 24 hours D24 hours

Patient's/Guardian's Signature: _ Date: __