3. How Long Has This Been An Issue?

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1 NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone: ( ) - (Cell) Phone: ( ) - (Home) Spouse/Partner Name: Address: In case of emergency, contact: Phone: ( ) - Relationship: Name of Medical Dr(s) Have you been to a chiropractor before? Yes No Who may we thank for referring you to our office? I authorize the doctor or his staff to render care as deemed appropriate for me and / or my child. I authorize Aspire Chiropractic to release and/or request records to or from other providers as may be necessary. I understand I am responsible for all bills incurred in this office. I authorize assignment of my insurance benefits (if applicable) directly to the provider. Person responsible for this account if other than the patient? I understand that after any initial promotional services all care is rendered at usual and customary fees. For my balance my preferred payment method is: Cash Check Credit Card Car/Work Ins. Patient / Parent Signature REASON FOR SEEKING CARE 1. How Long Has This Been An Issue? 2. How Long Has This Been An Issue? 3. How Long Has This Been An Issue? What is your current ( ) and worst ( ) pain level? Please mark all areas of concern (Circle one/ Square one) Have you seen anyone for care No Yes Who Treatment given No Yes Effective No Yes Do any of these conditions affect: Sleep Driving Standing Work Sitting Daily Routine Other: Does anything make it better? Does anything make it worse? NOTES: Are you Pregnant? No Yes

2 HEALTH PROFILE What are your health goals? Is your current condition the result of: Auto Accident Work Injury of Injury: May we share information w/ your physician regarding our findings, conclusions and recommendations? Yes No Medication Reason for Taking Frequency Start GENERAL HEALTH HISTORY Headaches Digestive Problems Urinary Problems Migraines Pain All Over Easy Bruising Shortness Of Breath Tension / Irritability Tobacco Use Allergies / Asthma Chest Pains Dental Problems Medication Side Effects Heart Pacemaker Fibromyalgia Diabetes Heart Problems Blood Thinner Use Cold Hands Or Feet Sleeping Problems TMJ Muscle Aches Vision Problems Cancer Trouble Walking Thyroid Problems Depression Leg / Foot Numbness Liver Disease Alcohol Use Fainting Kidney Problems High Low Blood Pressure Gall Balder Trouble Sensitive To Light Stroke History Ringing In Ears Ear Problems High Cholesterol Other Has Any Doctor Or Other Professional Advised You To Go To A Chiropractor? Yes No Name PAST HISTORY Any past auto accidents (date) Was any care received No Yes Any past work injuries (date) Was any care received No Yes Any past sport injuries (date) Was any care received No Yes Any past conditions and/or treatment received Any past hospitalizations or surgeries received FAMILY HISTORY Fathers Side Heart disease Cancer Diabetes Arthritis Other: Mothers Side Heart disease Cancer Diabetes Arthritis Other: Any other pertinent family history? Please list the cause of death and age of any immediate family members (Parents, Siblings, Children)

3 FUNCTIONAL RATING INDEX Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX For use with Neck and/or Back Problems In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday. For each item, please circle the number which most closely describes your condition right now. 1) Pain Intensity 6) Recreations [0] [1] [2] [3] [4] [0] [1] [2] [3] [4] No pain Mild Pain Severe Pain Worst Pain Can do all Pain Can do most Can do some Can do a few Cannot do any 2) Sleeping 7) Frequency of Pain [0] [1] [2] [3] [4] [0] [1] [2] [3] [4] Perfect Sleep No pain Intermitten Mildly Disturbed ly Greatly Totally Occasional pain; 25% t pain: 50% Frequent pain: 75% Constant pain: 100% of the day 3) personal care (washing, dressing, etc) 8) Lifting [0] [1] [2] [3] [4] [0] [1] [2] [3] [4] No pin; no restriction Mild pain, no restrictions pain, need to go slowly pain. Need some assistance Severe pain. Need 100% assistance No pain with heavy heavy moderate light any 4) Travel (driving, etc) 9) Walking [0] [1] [2] [3] [4] [0] [1] [2] [3] [4] No pain on long trips Mild pain on long trips pain on long trips pain on short trips Severe pain on short trips No pain, any distance 1 mile ½ mile ¼ mile all walking 5) Work 10) Standing [0] [1] [2] [3] [4] [0] [1] [2] [3] [4] Can do Can do Can do 50% Can do 25% Cannot No pain usual work usual work, of usual of usual work after any plus unlimited extra work no extra work work work several hours several hours 1 hour ½ hour standing Name: ID#: Group #: Signature: : Score:

4 AUTHORIZATIONS AND RELEASES Patient s name: of Birth: SS#: Authorization and Agreement for Payment of Services Rendered: I authorize Aspire Chiropractic to release any information deemed appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claims for reimbursement of charges incurred by me. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that if any amount is authorized to be paid directly to this office, it will be credited to my account upon receipt. I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR THE PAYMENT OF MY ACCOUNT. It is the policy of this clinic to collect for services as they are rendered, unless other financial arrangements are made. Patient Name Signature Signature of parent or guardian

5 INFORMED CONSENT FOR EXAMINATION AND TREATMENT This document explains some potential risks associated with chiropractic care. Please read this information carefully, and let our staff know if you have questions. The doctors and staff of Aspire Chiropractic will do everything to assist you with your health, or your condition. Please be aware that, as with all healthcare systems, we cannot guarantee a cure or resolution of your problem. While chiropractic care is remarkably safe, there are some risks associated with it, and we feel you need to be fully informed about these risks before consenting to treatment. Soreness Chiropractic adjustments and associated therapies may sometimes cause post-treatment soreness. While soreness is usually mild and temporary, please advise your doctor if you experience this. Soft Tissue Injury Rarely, chiropractic treatment may aggravate a disk injury, or cause other minor joint, ligament, tendon or other soft tissue injury. Rib Injury Adjustments to the mid back, in rare cases, may cause rib injury or fracture. Precautions such as preadjustment x-rays are taken for cases considered at risk for fracture. Treatment is performed carefully to minimize such risk. Physical Therapy Burns Heat generated by physical therapy modalities may cause minor burns to the skin. This is rare, but if it occurs you should report it to your doctor. Stroke Stroke is the most serious complication of chiropractic care, but fortunately its occurrence is extremely rare. The most recent studies estimate that the incidence of this type of stroke is one in five million neck adjustments. Other Complications There are occasionally other types of side effects associated with chiropractic care. While these are rare, they should be reported to your doctor promptly. We will make every reasonable effort during examination to screen for potential risks. Please be aware that if you have a condition that would otherwise not come to our attention, it is your responsibility to inform the doctor. I, the undersigned, agree that I have read, or have had read to me, and understand the information stated above. I hereby authorize the doctors and staff of Aspire Chiropractic to perform examination procedures and administer treatment to me, or to the person listed below for whom I serve as legal guardian. I understand that all procedures and treatment will be explained to me before they are performed, and that I have the right to refuse any such procedures. Patient Name Signature Signature of parent or guardian