1020 Marie Ave. South Saint Paul, MN Phone (651) PATIENT APPLICATION FORM

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1 1020 Marie Ave. South Saint Paul, MN Phone PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in helping our patients achieve their highest level of health through our integrated approaches to spinal correction and wellness care. This allows our patients to achieve far superior results compared to most other systems. Please fill out the following pages by being as complete and accurate as possible. This assures that our doctor can create a wellness plan tailored specifically to your needs and to let you know if you are a case that we can accept. Please feel free to ask any questions or bring up any concerns you may have. We are here to help you. We look forward to assisting you on your path to wellness. Yours in Health, Dr. Gina And the Health 1st Team: Jess, Kaytee, and Robyn PATIENT APPLICATION SURVEY First Name: MI: Last Name: DOB: SSN: Home Address: City, State, Zip: Address: Cell Phone: Home Phone: Work Phone: Occupation: Marital Status: S M Other Employer: Primary Care Physician: Office Location: Emergency Contact: Phone:

2 Referred By: PURPOSE OF THIS VISIT Reason for this visit Main Complaint: Is this purpose related to an auto accident / work injury? YES NO If so, what is the date of injury? If no, when did your condition begin? How did it begin? Gradual Sudden Progressive over time What activities aggravate your symptoms? Is there anything you can do to help relieve your symptoms? YES NO Describe: Type of pain: SHARP DULL ACHE BURN THROB SPASM NUMB TINGLING SHOOTING Does the pain radiate into you: ARM LEG DOES NOT RADIATE Is this condition getting worse? YES NO How often do you experience these symptoms throughout the day? 100% 75% 50% 25% 10% Does complaint 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? What are your expectations for care at our clinic? EXPERIENCE WITH CHIROPRACTIC Have you seen a chiropractor before? YES NO Who? When? Reason for visit: How did you respond? Did he/she take X-Rays? YES NO Did you know posture determines health? YES NO 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: The most common postural weakness is Forward Head Syndrome (head and neck starting to bend forward and progressively moving downward weakening your whole body). Even less severe forms of this posture can cause many adverse effects on your overall health. 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

3 HEALTH & LIFESTYLE Do you exercise? YES NO How often? 1x 2x 3x 4x 5 x per week other: What activities? RUN JOG WEIGHT TRAIN CYCLE YOGA OTHER what? Do you smoke? YES NO How much? How long? Do you drink alcohol? YES NO How much/wk? Do you drink caffeine? YES NO How much/day? Do you take any supplements? (i.e. vitamins, minerals, herbs) Do you take prescription medication? YES NO If Yes, Please write them on the back or provide a list. HEALTH CONDITIONS: Abnormal posture 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. Subluxations are caused by stressors (physical, chemical, and emotional) and have many serious adverse effects on your overall health. Please check any health condition you may be experiencing either now or in the past, these conditions can be directly related to your spinal health. CERVICAL SPINE (NECK): A subluxation in your neck will weaken the nerves to your arms, hands and head affecting these parts of the body. Do you experience (circle all that apply): Neck Pain Headaches Sinusitis Pain into your shoulders/arms/hands Dizziness Allergies Numbness/tingling in arms/hands Visual disturbances Recurrent colds/flu Hearing disturbances Coldness in hands Low energy/fatigue Weakness in grip Thyroid conditions TMJ/pain/clicking

4 THORACIC SPINE (UPPER BACK): A subluxation in your upper back will weaken the nerves to the heart stomach and lungs as well as affect these parts of the body. Do you experience (circle all that apply): Heartburn/Reflux Heart murmurs Tachycardia Heart Attacks/angina Recurrent Lung Infections/Bronchitis Asthma/wheezing Shortness of breath Pain on deep inhalation/exhalation LUMBAR SPINE (LOW BACK): A subluxation in your low back will weaken the nerves to your legs/feet digestive and pelvic organs affecting these parts of the body. Do you experience (circle all that apply): Pain into your hips/legs/feet Numbness/tingling in your legs/feet Coldness in your legs/feet Muscle cramps in your legs/feet Constipation/diarrhea Weakness/injuries in your hips/knees/ankles Recurrent bladder infections Frequent/difficulty urinating Menstrual irregularities/cramping Infertility Please list any health conditions not mentioned: GOALS FOR MY CARE Indicate all statements that apply to you: I have a specific health concern I want to ensure that my health concerns do not become an ongoing problem I am interested in learning how to improve my quality of life Are you healthier now than you were a year ago? YES NO If yes, what did you do to accomplish this? Is it your goal to be healthier 1 year from now than you are today? YES NO Do you have a plan on improving your health? Have you ever been advised on lifestyle choices for good health? YES NO Would you be interested in learning about nutrition, exercise, and stress reduction techniques? YES NO

5 TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both the doctor and the patient to be working toward the same objective. This will help prevent any confusion or disappointment. Consent for Treatment: We do not offer to diagnose or treat any disease or condition other than the vertebral subluxation. However, if during the course of a chiropractic evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Initial Authorization to Release Medical Information: I authorize the release of any medical information to process my insurance claim(s) and also certify that all insurance information given to this clinic is correct and complete. I understand that this office will not release any information for any other reason without written consent. Initial Request for Payment of Benefits to Provider of Care: I, herby authorize my insurance provider to pay by check and for it to be mailed directly to: Health 1 st Chiropractic & Wellness Center, the expense benefits allowable, and otherwise payable to me under my current policy, as payment towards the total charges for the professional services rendered. I have agreed to pay in a current manner any balance of said professional charges. I agree that this office be given power of attorney to endorse/sign my name on any and all drafts for payment of my bill. Initial I, have read and fully understand the above statement. (Please print) Consent for Treatment of a Minor: I hereby authorize the doctors of Health 1st to administer chiropractic care as they deem necessary to (Name). (Relationship to patient)

6 CREDIT POLICY I, herby understand that all charges incurred in our office are my responsibility. I will receive a statement from our office. All charges are due within 30 days of the statement issue date. Any amount 60 days or older will be subject to a collection fee of 40%. Initial For your convenience, we accept cash, check, Visa, MasterCard, Discover, and Care Credit. Our return check fee is $25. Initial If you have insurance coverage, you will need to present a CURRENT insurance card with picture ID at the time of service. Failure to do so will release Health 1 st Chiropractic & Wellness Center from any responsibility for incorrect or untimely filing of contracted claims. In the event of any insurance change, you are responsible to notify our office immediately to ensure proper billing. A copy of your new card will be required. We are in-network with many PPO organizations. Please check with your insurance provider to determine if Premier Health of South Saint Paul is participating with your plan. As of 2014, we are out of network with Preferred One and Blue Cross Blue Shield. Any payments or explanation of benefits will be sent to the patient. It is the responsibility of the patient to bring those in for any deductions or payments to be applied to the outstanding balance. Initial If your insurance requires a deductible, co-payment or coinsurance; it is due at the time of service. Please be prepared to pay this at each visit unless a prior payment schedule has been established in writing. Initial I have read and understand the above statements. Patient Signature: Date: Relationship to patient IF not self:

7 HEALTH 1st CLINIC INFORMATION We are a world class team that takes pride in passionately connecting with every patient in order to achieve world class health care. It is our experience that our patients who follow these simple guidelines obtain the best results and greatest benefits to their health. Clinic Hours: Monday, Wednesday, Thursday 8:30-12 and 2-6 Saturday 8:30-10:30 Initial Visit: The initial visit fee of $49.00 is due at the time of service with Dr. Gina. Initial Missed Appointments: All missed appointments should be made up later the same day or within 24 hours. A personal appointment calendar has been designed specifically for you and because each visit builds upon the last, it is imperative to stay on your schedule in order to achieve maximum benefit. Family: We are a family practice that takes pride in taking care of you and your family. For that reason every member of your family needs to have their own spinal check-up, especially your children (while growing, the spine is constantly changing). Financial Agreement: If for any reason you cannot keep your financial agreement, please inform us immediately. If you have the desire to receive care in our office we will make every attempt to make an affordable arrangement. In the unlikely event it is necessary to discontinue your care, or if we regretfully find it necessary to discharge you from our care, any outstanding fees become due immediately. Any credit on account must be used within 30 days and is non- transferable. Initial Please Remember: Spinal correction and healing takes time. To get the best results it is necessary for you to complete your treatment schedule and any home exercises that you have been prescribed. Each treatment builds upon the last. If you miss one of your scheduled appointments it will affect your results. If at any point you are not happy with your care or quality of service, please bring it to the attention of the Dr. or one of the assistants immediately.

8 WHAT TO EXPECT AFTER YOUR FIRST ADJUSTMENT Please read the following information carefully. When you are finished reading and all your questions have been answered, please sign and date to indicate that you fully understand the instructions and information given. 1) If you have never been adjusted, or it has been awhile since your last adjustment, you may experience soreness or discomfort for a few hours to a few days. This is a normal reaction to chiropractic adjustments. 2) If you are sore, use ice packs on the affected area. Ice therapy consists of the use of ice packs at 20- minute intervals followed by 40 minutes rest. This can be repeated as often as needed. Do not apply ice directly to bare skin. Always protect your skin with a thin covering such as a shirt or light towel. Cover the ice pack with a thick towel to retain its coldness. 3) Do not use heat without the doctor s instruction. Heat may aggravate your injury. 4) Stay away from heavy lifting or repetitive movements until the doctor indicates you are ready for normal activities. Strenuous athletic activities such as running, lifting weights, impact aerobics, racquetball, tennis, skiing, bowling, etc. should be avoided. Other things to avoid are yard work such as raking, digging, lifting heavy items such as groceries, pets, children, and any other activities that could aggravate or re-injure your condition. 5) Unless indicated by the doctor, you may return to work/school after your appointment. 6) If sudden movement causes sharp or severe pain, or if you experience swelling, contact the clinic at. 7) I have read and understand the instructions given for my follow-up care. Patient Signature: Date:

9 Name (Please Print): INITIAL REPORT Please mark your areas of pain on these figures, indicating which type of pain you are experiencing: A = ACHE/DULL PAIN B = BURNING PAIN S = STABBING/SHARP PAIN N = NUMBNESS P = PINS & NEEDLES/TINGLING Please mark the intensity of pain you are experiencing on the pain scale: No Pain Mild Discomforting Distressing Horrible Unbearable Please mark the percentage of the day you experience this pain: 10 / 20 / 30 / 40 / 50 / 60 / 70 / 80 / 90 / 100 Daily Activities: Effects of Current Condition on Performance (Circle all that apply): Bending No Effect Mild Pain Moderate Pain Severe Pain Standing No Effect Mild Pain Moderate Pain Severe Pain Climbing Stairs No Effect Mild Pain Moderate Pain Severe Pain Kneeling No Effect Mild Pain Moderate Pain Severe Pain Lifting No Effect Mild Pain Moderate Pain Severe Pain Sleep No Effect Mild Pain Moderate Pain Severe Pain Walking No Effect Mild Pain Moderate Pain Severe Pain Driving No Effect Mild Pain Moderate Pain Severe Pain Self-Care (dressing/bathing) No Effect Mild Pain Moderate Pain Severe Pain Sitting No Effect Mild Pain Moderate Pain Severe Pain Other No Effect Mild Pain Moderate Pain Severe Pain Patient Signature: Date:

10 WHAT S YOUR WELLNESS SCORE? Never been adjusted. NERVOUS SYSTEM EXERCISE Active Chiropractic Exercise, what s that? SLEEP Consistent 6 days/week Cardio & resistance Wake up every 2 hours, daily MENTAL STRESSORS Uninterrupted 8+ hours. Sleep nightly w/o sleep aid Commonly experience anxiety and/or negative thoughts DIET Carefree, stress free, and positive thinker Common western, high carb diet frequent soda/coffee Consistent organic Paleo Diet