!"#$%#&'()*$+(,-'#$ 846 Laurel Avenue Saint Paul Minnesota Fax:

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1 "#$%#&'()*$+(,-'#$ 846 Laurel Avenue Saint Paul Minnesota Fax: GENERAL INFORMATION Date.. Name SS #. FIRST MIDDLE LAST Address STREET CITY STATE ZIP + 4 Name you like to be called:. Are you: Retired Employed Self-Employed Phone numbers: Cell Work. Home Age.. Date of birth Gender: Female Male Lifestyle: Single Married Living with partner Separated Divorced Widowed Number of children.. Names and ages of children. Reason(s) you are consulting our office (check all that apply):.. I have a specific problem and want help with eliminating this problem.. I wish to participate in strategies to insure the problem does not return.. In addition to the above, I want to learn and do more to improve my general health.. I have no current symptoms and feel well. I want to learn ways to keep or improve my current state of wellness Major Complaint When did the problem start? Have you had this problem before? Yes No Payment is expected at time of service (exceptions are Personal Injury, Workers Comp, Medicare and Medical Assistance) Payment plans: Cash, check or charge card Auto accident Medical Assistance Workers Compensation Personal Injury Medicare I understand and agree that health and accident insurance policies are an arrangement between my insurance carrier and me. Furthermore, I understand that Dr. Clarke will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Dr. Susan Clarke will be credited to my account on receipt. I understand and agree that all services rendered me by Dr. Susan Clarke are charged directly to me and that I am personally responsible for payment. I understand and agree that if I suspend or terminate my care and treatment, any fees for professional services rendered me by Dr. Susan Clarke will be immediately due and payable. PATIENT S SIGNATURE.. Date PARENT S SIGNATURE (if patient is under 18 years of age). Page 1 of 4

2 The following questions deal with the complaint you came in with and also your personal history. Answer what you can, and if you cannot remember or do not know, just pass over the question. Please rate your spinal pain and/ or tenderness: Chief Spinal Complaint and Location: Neck Upper Back Mid Back Low Back Sacrum Is the pain present: 25% 50% 75% of the time? Second Spinal Complaint area (if present) Neck Upper Back Mid Back Low Back Sacrum Is the pain present 25% 50% 75% of the time? How does the discomfort or pain feel? Dull Sharp Stabbing Burning Shooting Sudden Tingling Pins and Needles Rate the pain and/ or discomfort on a scale of 1-10 (10 = unbearable; 1 = slight and intermittent) What increases the pain? Standing Sitting Lying down Walking Lifting Exercise Stretching Heat Cold Twisting Bending Other. Was the onset of the paingradual? Sudden? What lessens the pain? Standing Sitting Lying down Walking Lifting Exercise Stretching Heat Cold Twisting Bending Other. Other complaints of pain, tenderness or dysfunction: Shoulder (right left) Elbow (right left) Wrist (right left) Chest (right left Ribs (right left) Stomach Lungs (right left) Upper Abdomen Lower abdomen Hip (right left) Knee (right left) Ankle (right left) Foot (right left) Head (right: left: on top: back of neck) Skin problems where? Other issues: Post Traumatic Stress Disorder Anxiety Depression Easily upset Flash-backs Inability to focus Other.. PERSONAL HISTORY Have you ever been to a Doctor of Chiropractic or a Doctor of Osteopathy before? Yes No Dr(s) name(s) If yes, when was your last visit? How often did you go? For how long were you going?. Why did you stop?..... Have you had x-rays taken of your spine? Yes No Page 2 of 4

3 Have you done, or are you still doing any of the following to help with your health? Network Chiropractic Massage Rolfing Feldenkreis Psychotherapy Yoga Aerobics Weight training Re-birthing Prayer Other.. Chiropractic care is based on the location and adjustment of vertebral subluxations and extremity subluxations. These are caused by any stress on your body which your body cannot properly perceive, adapt to, or recover from. These stresses can be PHYSICAL, CHEMICAL or EMOTIONAL in nature. To help you better in any of these areas, please answer the following questions: PHYSICAL STRESS How do you grade your physical health? Excellent Good Fair Poor Improving Worsening BIRTH HISTORY Are you adopted? Yes No (If you are adopted and have no biological family history, you can skip the rest of this section) Did your mother have a difficult pregnancy with you? Yes No If yes, please explain.. Did your mother have any illnesses, accidents or any other physical trauma during pregnancy? Yes No If yes, please explain. Was your birth delivery traumatic? Yes No If it was traumatic, what happened? Drugs induced Forceps or suction Breech C section Cord around neck Prolonged CAR ACCIDENTS Have you ever been in a motor vehicle accident (as driver, passenger, been hit by a car when walking or on a bike)? If so, please give date(s) of accidents.. and rate the severity: Mild Moderate Severe If in a car, were you Rear-ended Side-swiped Head-on collision CHEMICAL TRAUMA Do you now, or did you work with chemicals, fumes, dust or smoke for long periods? Yes No Are you currently taking any drugs? Yes No Herbs? Yes No Vitamins and minerals? Yes No What kind(s) of food do you eat? What do you drink? And how often do you eat and drink it? Alcohol Coffee Sodas.. Water. Tobacco Nutrasweet Splenda.. Diet food. Low Fat Junk food Fast food Candy. Add salt to food White bread/ pasta Frozen food Canned food.. Fried food Whole grains Pork Beef.. Lamb Chicken Turkey... Fish Shellfish Eggs Raw food. Organic food. GENERAL PHYSICAL TRAUMA Have you ever had any injuries that took you out of commission for a day or more? Yes No Describe Page 3 of 4

4 Have you ever been knocked unconscious? Yes No Describe Have you ever used crutches, a walker or a cane? Yes No Describe Have you ever broken any bones? Yes No Have you ever had any impacts, falls, or jolts that you felt specifically injured your head or spine? Yes No Have you ever been hospitalized? Yes No Have you ever had extensive dental or orthodontic work done? Yes No If so, what for? How much do you exercise? Not at all Occasionally Several times per week Daily EMOTIONAL TRAUMA Have you ever suffered from, or are you still undergoing abuse? Sexual Yes No Mild Moderate Extreme Verbal Yes No Mild Moderate Extreme Psychological Yes No Mild Moderate Extreme Have you been well all your life? Yes No If not well, for either part or all of your life, please rate your experience. Mild Moderate Extreme Have you had people you love die? Yes No If so, what was their relationship to you and when did they die? Have you been married more than once? Yes No If so, how many marriages and divorces have you had? Do you consider your emotional and mental health to be Excellent Good Fair Poor Getting better Getting worse Is there anything else that has not been covered in this questionnaire that you wish Dr. Susan Clarke to know about? Page 4 of 4

5 The Healing Circle 846 Laurel Avenue, Saint Paul, MN Fax: SUSAN CLARKE DC INFORMED CONSENT for CHIROPRACTIC CARE You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment that will be provided at this clinic. You may make the decision whether or not to use chiropractic care after being advised of the known benefits, risks and alternatives. Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect both the restoration and the preservation of health. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the twenty four vertebrae in the spinal column become misaligned and/ or do not move properly. This causes alteration of nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic. Subluxations are corrected and/ or reduced by an adjustment (a specific application of forces to correct and/ or reduce vertebral subluxations). Our chiropractic method of correction is by specific adjustment of the spine. In this clinic this is usually done by hand, but may be performed by handheld instruments. In addition, ancillary procedures such as physiotherapy and/ or rehabilitative procedures may be included. If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider. All questions regarding Dr. Clarke s objective pertaining to the care in this clinic has been answered to my complete satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. NAME.. DATE SIGNATURE.. Consent to evaluate and adjust a minor child: I,.. being the parent or legal guardian of. have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care. InformedConsent/October2010

6 The Healing Circle 846 Laurel Ave, Saint Paul, MN Fax SUSAN CLARKE DC PATIENT HEALTH INFORMATION CONSENT FORM This is to let you know how your Patient Health Information (PHI) is going to be used in this office, plus let you know your right concerning your records. (HIPAA) Before I begin any health care procedure, I request you read and sign this consent form stating you understand and agree with how your records will be used: 1. You understand and agree to allow the Healing Circle (THC) (Dr. Susan Clarke and her staff) to use your PHI for the purpose of treatment, payment, healthcare operations, and coordination. You agree to allow Dr. Clarke to submit requested PHI to the Health Insurance Company (or companies0 for payment. 2. You have the right to examine and obtain a copy of your records at any time. You may request corrections. You may ask to know what disclosures have been made and submit, in writing any further restrictions on the use of your PHI. Dr. Clarke is not obligated to agree to those restrictions. 3. Your written consent need only be obtained one time for all subsequent care given to you at this office. 4. You may provide a written request to revoke consent at any time during care. This would not affect the use of those records covering the care given prior to the written request, but would apply to any care given after the request is presented. 5. For your security and right to privacy, all staff at Dr. Clarke s clinic have been trained in the area of patient record privacy and Dr. Susan Clarke has been designated to enforce those procedures. Dr. Clarke has taken all precautions known by this office to assure your records are not readily available to others. 6. You have a right to file a formal complaint with Dr. Susan Clarke about any possible violation of these policies and procedures. 7. If your refuse to sign this consent for the purpose of treatment, payment and health care operations Dr. Susan Clarke has the right to refuse to give care. I, have read and understand the policies and procedures regarding usage of my Patient Health Information, and I agree to these policies and procedures. SIGNATURE.. DATE HIPAAform/October2010