PATIENT APPLICATION FORM

WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very unique and advanced from other rehabilitative programs. This allows our patients to achieve far superior results compared to most other systems. Please fill out the following information thoroughly so the doctor can let you know if you are a case we can accept. Please feel free to ask any questions if you need assistance. We look forward to serving you.

_________________________________________________ Patient Signature: __________________________________ Today’s Date:

PATIENT APPLICATION SURVEY Name: (Last) ___________________________________ (First) _________________________ Age _______ Gender: M F

Home Address: __________________________________________________ Home Phone: ( ) _________________________

City ___________________________ State ________________ Zip _________Work Phone: ( ) _________________________

Cell Phone Provider: _______________________________________________Cell Phone: ( ) _________________________

Birth Date: ______ / ______ / _______ Social Security #: ________ - ______ - _________ Marital Status: Single Married

Email Address: ________________________________________________________________ Divorced Widowed

Names of Children: ___________________________________________________________________ Ages: ____________________

Occupation: __________________________________________________ Employer Name: _______________________________________

Employment: (Please Circle) Full Time Part Time Retired Unemployed Insurance Co: ____________________________________

Spouse’s Name: __________________________ Work Phone: ( ) __________________ Cell Phone: ( ) ________________________

Spouse’s Employer: _________________________________________ Occupation: _______________________________________________

How were you referred to this office? _____________________________________________________________________________________

PURPOSE OF THIS VISIT

Reason for this visit: Primary Complaint: __________________________________________________________________________________

Secondary Complaint: ________________________________________________________________________________

Is this visit related to an auto accident / work injury? � Yes � No If so, when: ________________________________________________

If no, what was the cause of your major complaint? __________________________________________________________________________

When did this complaint begin? __________/_____/________ Did it begin: Gradual Sudden Progressive over time

What activities aggravate your symptoms? ____________________________________________________________________________

Is there anything which has relieved your symptoms? � Yes � No Describe:__________________________________________________

On the diagram to the right, please show where your complaints are, using the following letters:

A: ache B: burning pain T: tingling N: numbness S: sharp pain

C: cramping D: dull pain

Does your pain radiate?_______ Where does it radiate to? _________________________

Is this condition getting worse? � Yes � No

On the scale below, please circle the severity and intensity of your primary complaint (at its worst):

None Slight Mild Moderate Severe

1 2 3 4 5 6 7 8 9 10

On the scale below, please circle the percentage of time you experience your primary complaint: Occasional Intermittent Frequent Constant

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Does your complaint(s) interfere with: __Work __Sleep __Hobbies __Daily Routine Explain: ____________________________________

Have you experienced this condition before? � Yes � No If so, please explain: _________________________________________________

Who have you seen for this? ______________________________________ What did they do? _________________________________

How did you respond? ___________________________________________________________________________________________

EXPERIENCE WITH CHIROPRACTIC Have you seen a Chiropractor before? � Yes � No Who? __________________________________ When? ________________________

Reason for visits: _____________________________________________________________________________________________________

How did you respond? _________________________________________________________________________________________________

Did your previous Chiropractor take before and after x-rays? � Yes � No

Did you know posture determines your health? � Yes � No

HEALTH LIFESTYLE Are you aware of any of your poor posture habits? � Yes � No

Explain: _________________________________________________________________________________________________________

Are you aware of any poor posture habits in your spouse or children? � Yes � No

Explain: _________________________________________________________________________________________________________

HEALTH CONDITIONS Abnormal postural habits or distortions are the result of trauma or stress to the body that have misaligned the vertebrae in your spine. When these vertebrae are twisted from their normal position, they will cause stress to the spinal cord and the delicate nerves that pass between the vertebrae. These misalignments are called Subluxations (sub-lux-a-shuns). It has been extensively documented that subluxations, causing stress to your nerves, will weaken and distort the overall structure of your spine. This results in a weakened and distorted POSTURE. Postural distortions have many serious and adverse effects on your overall health. The most common and detrimental postural distortion is called Forward Head Syndrome (a “hunched forward” posture starting in the neck and progressively moving down your spine weakening the entire body).

Have you ever been told or felt like you carry your head forward, noticed a rounding of your shoulders or a developing “hump” at

the base of your neck? Yes No

Do you exercise? Yes No How often? 1X 2X 3X 4X 5X per week other: ___________________________________________

What activities? (Please Circle) Running Jogging Weight Training Cycling Yoga Pilates Swimming

Other: _________________________________________________________________________________________ ________________

Do you smoke? Yes No How much? ________________________________________________________________________

Do you drink alcohol? Yes No How much / week? _______________________________________________________________

Do you drink coffee? Yes No How many cups / day? ____________________________________________________________

Do you take any supplements (i.e. vitamins, minerals, herbs)? __________________________________________________________

Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above Doctor and his Associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual cycle: ______________________ _____________________________________________ _____________________ Signature Date Consent to X-Ray: I hereby grant Complete Chiropractic Life Center permission to perform an x-ray evaluation if needed. I understand that x-rays are being performed to locate vertebral subluxation and not to diagnose or treat any other disease or condition. _____________________________________________ ______________________ Signature (parent if minor) Date

POLICIES

1. All first visit charges are payable when services are rendered.

2. The fee paid for treatment x-rays is for analysis only. X-rays are the property of this office and are used for treatment purposes. A copy of your x-rays may be requested for a $20 fee.

3. I understand and agree that if I suspend or terminate my care at this clinic, any outstanding charges for professional services rendered to me will be immediately due and payable. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to collect this account. If any account balance remains unpaid for three months or longer, a monthly interest fee of 2% will apply to the account balance. I authorize Complete Chiropractic Life Center to obtain a credit report if deemed necessary.

INSURANCE INFORMATION

I clearly understand that all insurance coverage is an arrangement between my insurance carrier and me. If this office chooses to bill any services to my insurance carrier they are performing these services strictly as a convenience for me. This office will provide any necessary report or required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny any claim and that I am ultimately held responsible for any unpaid balances. Any monies received will be credited to my account. I certify that this office visit is not related to any personal injury or worker’s compensation case that is active or that has not been closed and finalized. Signature__________________________________________________ Date _____________________ (If under age 18) Parent’s signature EMERGENCY INFORMATION In case of emergency notify: ______________________________________________________________________ Relationship: ___________________________________ Emergency Phone: _______________________________

Patient Name:______________________________________________ Date:_____________________

Check below any conditions you are experiencing, past or present!

Please list any health conditions not mentioned: ___________________________________________________________________________ Please list any medications currently taking and their purpose : _________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________ Please list all past surgeries: ____________________________________________________________________________________________ Please list all previous accidents and falls: ________________________________________________________________________________

TERMS OF ACCEPTANCE

When a person seeks chiropractic and rehabilitation health care and is accepted for such care, it is essential for both parties to be working towards the same objective. As a Chiropractic facility we have one main goal, to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express it’s maximum health potential.

We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. Regardless of what a disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our Only Practice Objective is to eliminate a major interference to the expression of the body’s innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations combined with rehabilitation procedures. NOTE: It is understood and agreed the amount paid to Complete Life Chiropractic Center for x-ray, is for examination only and the x-rays will remain the property of this office, being on file where they may be seen at any time while a patient of this office.

CONSENT TO CARE

I do hereby authorize the Doctors of Complete Chiropractic Life Center to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments and other Chiropractic procedures, including various modes of physical therapy and diagnostic x-rays or any other procedure that is advisable, and necessary for my health care.

Furthermore, I authorize and agree to allow the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the Doctor of Chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function.

I have had an opportunity to discuss with the Doctor of Chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not.

I understand and informed that, as in the practice of medicine, in the practice of Chiropractic there are some risks to treatment including, but not limited to fractures, disk injuries, strokes, dislocations and sprains. I do not expect the Doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the Doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. The Doctor will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions treated at this clinic.

I also clearly understand that if I do not follow the Doctor’s specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor. I, _________________________, have read or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent, and by signing below I agree to the above-above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment. Signature_________________________________________ Date _______________ (If under age 18) Parent’s Signature

Acknowledgement of Receipt of Notice of Privacy Practices

5225 Cleveland Rd., Suite A Wooster, OH 44691 (330) 345-3336

In the course of your care as a patient at Complete Chiropractic Life Center, we may use or disclose personal and health related information about you in the following ways: your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment, your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services. Your name, address, phone number and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message may be left on your answering machine. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form please advise us in writing as to your preferences. Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances: If we are providing health care services to you based on the orders of another health care provider, if we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so, if there are substantial barriers communicating with you, but in our professional judgment we believe you intend for us to provide care, if we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. In addition, you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of activities you should direct your complaint to the Privacy Officer, Dale C. Capela, D.C. at 5225 Cleveland Rd. Ste. A., Wooster, OH 44691 (330)345-3336. If you would like further information about our privacy policies and practices please contact: Dale C. Capela, D.C. This office utilizes an “open treatment” environment for ongoing patient care. “Open treatment” involves the possibility of other patients being seen in the same “treatment environment” at the same time. Patients are within sight of one another and some ongoing routine details of care are discussed within hearing of other patients and staff. A private, closed and confidential setting is provided for history taking, examinations, report of findings, etc. as determined by the doctor or staff. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. If you choose not to be adjusted or use traction in an “open treatment” environment other arrangements will be made for you. This office also requests the presence of your spouse or significant other at your Report of Findings appointment for purposes of health education. This notice is effective as of _______________________. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice. ______________________________________ _______________________________________ ________________ Printed Name Signature Date

5225 Cleveland Rd., Ste. A Wooster, OH 44691

330.345.3336 www.completechirolife.com

Dale C. Capela, D.C. David C. Pamer, D.C.

The status of a person’s health directly impacts their ability to reach their life goals.

We want to help you live your life to your fullest God-given potential!

To help us better serve you, please list your health and life goals.

(Ex. playing with your children, grandchildren, climbing a mountain, running a marathon,

still being able to walk and play and enjoy life, etc…)

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______________________ _____________ Signature Date