Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code

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Ursula Roberts
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1 Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By Name of Spouse/Parent/Guardian How did you hear about us? Number of Children Occupation or Profession Have you had chiropractic care before? Yes No Where? Name and address of insurance company Name of primary insurance (if different from above) ID# Group # Group Name I understand that my insurance may not pay, either partially or fully. If this is the case, I agree to be fully responsible for paying for all charges incurred in this office. Patient Signature Primary insurance signature (if different from patient) 10/30/2013

2 Gordley Family Chiropractic Name Date: Please check the appropriate box for the following symptoms which you have now or have had previously. We want all the facts about your health before we accept your case. Your health report is confidential and is treated as such. General: Neck: Mid-Back: Hips, Legs & Feet Chills Sharp pain in neck Mid-back pain Pain in buttocks (R-L) Convulsions Neck pain with movement Pain between shoulder blades Pain in hip joint (R-L) Fever Stiff neck Sharp stabbing pain in mid-back Pain down thigh (R-L) Loss of sleep Muscle spasm in neck Muscle spasms Side of thigh (R-L) Loss of weight Grinding sounds in neck Chest: Back of thigh (R-L) Fatigue Grating sounds in neck Chest pain Front of thigh (R-L) Nervousness Popping sounds in neck Shortness of breath Groin (R-L) Depression Shoulders: Pain around ribs Pain down both legs Irritability Pain in shoulder joint (R-L) Pain on taking deep breath Pins & needles in legs (R-L) Numbness Pain between shoulders Abdomen: Numbness in legs (R-L) Sweats Numbness in shoulders (R-L) Nervous stomach Numbness in feet (R-L) Tension Nausea Numbness in toes (R-L) Head: Above shoulder level Gas Feet feel cold (R-L) Headaches Over head Constipation Pain in calf (R-L) Entire head Muscle spasm in shoulder Diarrhea Painful joints Back of head Arm & Hands: Vomiting Hips (R-L) Forehead Pain in upper arm (R-L) Vomiting of blood Knees (R-L) Temples Pain in forearm (R-L) Low Back: Ankles (R-L) Behind eyes Pain in hands (R-L) Low back pain Pain in feet or toes (R-L) Migraines Pain in fingers (R-L) Low back pain when: Swollen joints Head feels heavy Sensation of pins & needles in arm Working Hips (R-L) Lossof memory Sensation of pins & needles in fingers Lifting Knees (R-L) Light headedness Numbness in hands and fingers Sitting Ankles (R-L) Fainting Numbness in arm (R-L) Stooping Women Only Dizziness Swollen joints Standing Menstral pain Ringing in ears Loss of strength in arm (R-L) Walking Severe cramping Loss of smell Loss of grip Bending Irregular cycle Loss of taste Coughing Excessive flow Loss of hearing Low back feels out of place Backache Altered vision Muscle spasms ARE YOU PREGNANT? Light bothers eyes YES NO Fever What is your major complaint? Other complaints How long have you had this condition? Have you had this or similar conditions in the past? What activities aggravate your condition? Is this condition getting progressively worse? Yes No Constant Comes and goes Is this condition interfering with your: Work Sleep Daily routine Other 10/30/2013

3 Accidents, falls, fractures, dislocations, strains or sprains: Year Description Were you ever knocked unconscious Yes No Describe Are you taking any drugs or medications? (list type and for what condition) Surgeries: (list type & date) How long has it been since you have had: Chiropractic care: Complete physical exam: Blood pressure check: Chiropractic x-rays: IF YOURS IS A CAR ACCIDENT, ON-THE-JOB ACCIDENT OR PERSONAL INJURY OF ANY KIND PLEASE COMPLETE THE FOLLOWING: Date of accident Hour AM PM Location How did accident occur? Auto On-the-job Other Please describe the circumstances in your own words: Were there any other people involved in the accident? Yes No If Yes, please give their names: Symptoms other than above: Have you lost any days of work? Yes No Insurance Information My company Policy # Company of person responsible for injuries and address: Name of insured person: Name and address of Workmen's Compensation carrier if on-the-job injury: Do you have an attorney who has advised you in this case? Yes No His/her name and address 10/30/2013

4 GORDLEY FAMILY CHIROPRACTIC Dr. Megan E. Gordley th Street W Columbia Falls MT This is to verify that I have received a copy of the privacy policy according to HIPAA regulations for the office of: Dr. Megan E. Gordley Gordley Family Chiropractic th Street W Columbia Falls, MT 5912 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 is created. My signature acknowledges that I have received a copy of this notice. Name (please print) Signature Date If you are a minor, or if you are being represented by another party: Personal representative printed Personal representative signature Date Description to the authority to act on behalf of the patient

5 Gordley Family Chiropractic th St W Columbia Falls MT THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORAMTION. PELASE REVIEW IT CAREFULLY. In the course of your care as a patient at Gordley Family Chiropractic (GFC) 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 and 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. 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 heath care provider. If we provide health care services to you in an emergency. 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 to communicating with you, but in our professional judgment we believe that 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 outlined above, will only be made upon your written authorization. We normally provide information about 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 you account. If you would like to receive this information at an address other than you home, or if you would like the information in a different form please advise us in writing as to your preferences. You have the right to inspect and/or copy your health information.

6 Gordley Family Chiropractic, PL L C C O NSE N T T O T R E A T M E N T A ND R ESPO NSIBI L I T Y A G R E E M E N T Please read each section carefully. You may request a copy of this form for your own records. Please print your name: I, the undersigned, do hereby request and consent to the performance of chiropractic treatment and related physical therapy procedures upon the above-named patient (my dependent or myself). I wish to rely on the chiropractor to exercise judgment for my best interest during the course of treatment. I will inform the chiropractor or certified assistant who is treating me of any sensitive areas or adverse conditions I may have had prior to, during, or after treatment. I intend this consent to cover the entire course of treatment. I realize a notice of 24 hours is encouraged for canceled appointments. I understand that my time slot is only for me and that by skipping an appointment without canceling means that someone in need is unable to be seen. Therefore, canceling as early as possible is greatly appreciated to allow others my time slot. (Please call to cancel appointments.) I hereby authorize the release of my medical records and other information necessary to process insurance claims. I clearly understand and agree that all services rendered to me or to my dependent, the above-named patient, are charged directly to me and that I am personally responsible for payment. I understand that even if I suspend or terminate my treatment, any fees for professional services rendered to me will be immediately due and payable. Relationship to Patient: Signature:

Chiropractic Case History/Patient Information

Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital: