Please read carefully & check any of the symptoms that you have noticed since the accident or injury.

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Horace White
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1 127 W. Juanita Ave., Suite #110 Mesa, Arizna Patient s Accident Accunt Office (480) Fax (480) Patient Name Emplyer Patient Address Emplyer Address Patient Phne N. Emplyer Phne N. Emergency Cntact Name Emergency Cntact Phne N. Date f Accident _ Time AM/PM Lcatin f Accident r Injury Type f Accident (Select ne) Aut Cllisin Wrk Other Please describe the accident r injury (in as much detail as pssible) Aut Injury Questins: Were yu the (select ne) Driver Passenger Pedestrian Were yu struck frm (select ne) Behind Frnt Left Side Right Side Parked Did yur car strike thers invlved? Yes N Did the ther car strick yurs? Yes N Did yu have a seat belt n? Yes N Did any part f yur bdy strike the car? Yes N Which? Were traffic citatins issued t yu? Yes N Issued t ther drivers? Yes N T the driver f the car yu were in? Yes N Wrk Injury Questi ns: Was yur emplyer ntified? Yes N Did the emplyer refer yu anywhere? Yes N Please describe hw yu felt after the accident (in as much detail as pssible). Please read carefully & check any f the symptms that yu have nticed since the accident r injury. Headache Dizziness Lss f Memry Ringing in Ears Neck Pain Head Seems Heavy Face Flushed Ls f Balance Neck Stiff Pins & Needles in Arms Pins & Needles in Legs Fainting Sleeping Prblems Numbness in Fingers Numbness in Tes Cnstipatin Back Pain Shrtness f Breath Upset Stmach Diarrhea Nervusness Light Bther Eyes Tensin Cld Sweats Irritability Buzzing in Ears Depressin Chest Pain Cld Hands Lightheadedness D yu feel any ppping, tearing r ripping in yur neck r back? Yes N Did yu have any bruises? Yes N Where? Have yu ever been treated befre fr any f these symptms? Yes N Did yu g t the Emergency Rm? Yes N Where? Were yu examined? Yes N Were yu X-Rayed? Yes N Was there treatment given? Yes N Medicatin? Yes N Have yu seen ther dctrs? Yes N Wh? Have yu lst any days frm wrk? Yes N Hw many?

2 127 W. Juanita Ave., Suite #110 Mesa, Arizna Persnal Injury Insurance Infrmatin Office (480) Fax (480) Tday s Date: Accident Date: Name: Driver Passenger Please prvide as much infrmatin as pssible s that yur case can be set up t yur financial advantage. In the state f Arizna Insurance laws read that yu have the right t bill any insurance plicy under which yu have cverage. In the case f mre than ne insurance cverage, verpayment may ccur. We nly need t be paid nce. s all verpayments will be reimbursed t yu at the time yu are released frm care. Primary Insurance: (Health Insurance that cvers yu) Insured Name: Insurance Name: ID#: Grup Insurance Phne # _ Medical Payment Cverage: (One yur autmbile insurance, r the autmbile insurance fr the car in which yu were a passenger, there may be cverage called Medpay. This cverage is fr any injuries that may have ccurred t smene in the autmbile. It will cver anything frm an autmbile accident that either was r wasn t yur fault, t slamming yur finger in yur car dr. Using this prtin f the plicy cannt raise yur premium r effect yur recrds in any way. In fact, this is exactly why yu pay fr Medpay n yur insurance plicy). Claimant: Plicy Hlder s Name: Insurance Name: Phne #: Plicy #: Claim #: Adjuster s Name: Phne #: Plicy Verificatin by CA: Third Party Liability: This is the insurance infrmatin fr the persn wh was in the ther car. The infrmatin can be fund n the Accident Reprt. Driver s Name: Plicy Hlder s Name Insurance Name: Insurance Phne: Plicy #: Claim #: Adjuster s Name: Phne#: Plicy Verificatin by CA: Attrney Infrmatin: Name: Phne#:

3 127 W. Juanita Ave, #110 Mesa, AZ (480) / Fax (480) Name Address_ City State _ Zip Hme ph# Cell# (Fr cnfirming apt.): Address : SSN / / Date f birth / / Age Height Weight Male Female Single Married Divrced # f children Spuse s name Emplyer _ Address _ City State Zip _ Wk ph: Occupatin What is the name f yur family physician? _What city are they lcated in Have yu ever had Chirpractic care befre? If yes, dctr name: Date f last visit If yu are experiencing any pain (neck pain, lw back pain, etc.), health prblems, symptms, and/r cmplaints, please list in rder f severity 1. Fr hw lng? 2. Fr hw lng? 3. Fr hw lng? 4. Fr hw lng? Has this prblem been getting wrse staying the same? Currently r in the past have yu ever experienced any f these cmplaints while wrking? If yes, please describe what activities at wrk may be causing yu these cmplaints: Are there any ther activities, incidents, r events utside f wrk that may have caused these cmplaints? If yes, please explain: _ Have yu at any time in the past ever suffered a wrk injury? If yes, what is the date f injury? / / D yu have an attrney representing yu fr this wrk injury? yes n If yes, wh is yur attrney? Have yu been invlved in an aut accident in the last 12 mnths? yes n If yes, what is the date f injury? / / D yu have an attrney representing yu fr this aut injury? yes n If yes, wh is yur attrney? Hw many ther passengers were in the car with yu? List ther dctrs cnsulted fr these cnditins? 1) 2) If due t an aut accident, what is the name f yur aut insurance cmpany? Have yu ever had any surgeries r hspitalizatins? If yes, please list: Please list any current r past injuries and illnesses nt listed abve: Please check all medicatins (ver the cunter and/r prescribed) yu are currently taking: NSAID/Aspirin/Tylenl Pain killers Muscle Relaxer Insulin Birth Cntrl Pills Sleeping Pills Anti-depressants Others Health Insurance C. Name Plicyhlder Name f Spuse s health insurance (If applicable) Plicyhlder Spuse s Health Insurance Claims address Plicy number

The rating scale belw is designed t measure the degree t which several aspects f yur life are presently disrupted by yur health cnditin (pain and/r symptms yu may be experiencing).

4 The rating scale belw is designed t measure the degree t which several aspects f yur life are presently disrupted by yur health cnditin (pain and/r symptms yu may be experiencing). In ther wrds, we wuld like t knw hw much yur health cnditin (pain and/r symptms yu may be experiencing) is preventing yu frm ding what yu wuld nrmally d, r frm ding it as well as yu nrmally wuld. Respnd t each categry by indicating the verall impact f pain in yur life, nt just when the pain is at its wrst. Fr each f the six categries f daily living listed, PLEASE INDICATE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ACTIVITIES. 0 means n disability at all, and a scre f 10 means that all f the activities in which yu wuld nrmally be invlved have been ttally disrupted r prevented by yur health cnditin (pain and/r symptms yu may be experiencing) Cmpletely Ttally able t functin unable t functin 1. FAMILY/HOME RESPONSIBILITIES: activities related t the hme r family including chres and duties perfrmed arund the huse (yard wrk, ding dishes, errands, favrs fr ther family members, driving children t schl, etc) 2. RECREATION: hbbies, sprts, and ther similar leisure time activies. 3. SOCIAL ACTIVITY: activities which invlve participatin with friends and acquaintances ther than family members including parties, theater, cncerts, dining ut, and ther scial functins. 4. OCCUPATION: activities that are a part f r directly related t ne s jb including nnpaying jbs as well, such as that f a hmemaker r vlunteer wrker. 5. SELF CARE: activities which invlve persnal maintenance and independent daily living (taking a shwer, driving, getting dressed, etc.) 6. LIFE SUPPORT ACTIVITY: basic life supprting behavirs such as eating, sleeping, and breathing. RATE: If yu are experiencing any health prblems, please mark the exact lcatin f yur pain n the diagram belw. Als describe the type and frequency f yur pain. Fr example, dull, sharp, cnstant, ff and n, when standing, sitting, walking etc. COMPLETE THESE DIAGRAMS Methd f payment fr tday s charges: CASH CHECK CREDIT CARD NOTICE: NOT ALL PATIENTS REQUIRE X-RAYS TO DETERMINE TYPE OF CARE AND LENGTH OF CARE. IF YOUR EXAMINATION WARRANTS X-RAY ANALYSIS, THE FOLLOWING OFFICE POLICY PREVAILS: 1. All first visit charges are payable when services are rendered. 2. The fee paid fr x-rays is fr analysis nly. We are required t maintain yur riginal x-rays. The film itself is the prperty f this ffice. Films may be laned t anther health prvider with yur prir authrizatin nly. Patient s Signature Date 127 W. Juanita Ave., #110, Mesa, AZ (480) /12

5 127 W. Juanita Ave., #110 Mesa, AZ (480) / F (480) ACTIVITIES OF LIFE Please identify hw yur current cnditin is affecting yur ability t carry ut activities that are rutinely part f yur life. ACTIVITIES: EFFECT: Carry Children/Grceries! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Lift Children/Grceries! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Climb Stairs! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Pet Care! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Extended Cmputer Use! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Sit t standing! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Read/Cncentrate! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Getting Dressed! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Shaving! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Sexual Activities! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Sleep! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Prlnged Sitting! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Prlnged Standing! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Yard wrk! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Walking! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Washing/Bathing! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Sweeping/Vacuuming! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Dishes! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Laundry! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Garbage! N Effect! Painful (can d)! Painful (limits! Unable t Perfrm Driving! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Other:! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm _! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm _! N Effect! Painful (can d)! Painful (limits)! Unable t Perfrm Patient signature: Printed Name: Tday s Date: / / DSCC 2016

6 127 W. Juanita Ave., #110 Mesa, AZ (480) / F (480) Patient Name: Date: / / Please mark P fr in the Past, C fr Currently have, r Leave Blank if Never Headache Pregnant (Nw) Dizziness Prstate Prblems Ulcers Neck Pain Frequent Clds/Flu Lss f Balance Erectile/Sexual Dysfunctin Heartburn Jaw Pain, TMJ Cnvulsins/Epilepsy Fainting Digestive Prblems Heart Prblem Shulder Pain Tremrs Duble Visin Cln Truble High Bld Pressure Upper Back Pain Chest Pain Blurred Visin Diarrhea/Cnstipatin Lw Bld Pressure Mid Back Pain Pain w/cugh/sneeze Ringing in Ears Menpausal Prblems Asthma Lw Back Pain Ft r Knee Prblem Hearing Lss Menstrual Prblem Difficulty Breathing Hip Pain Sinus/Allergy Prblem Depressin PMS Lung Prblems Back Curvature Swllen/Painful Jints Irritable Bed Wetting Kidney Truble Sclisis Skin Prblems Md Changes Gall Bladder Truble Truble Sleeping Numb/Tingling arms, hands, fingers ADD/ADHD Eating Disrder Liver Truble Numb/Tingling legs, feet, tes Family Histry Cancer: Sibling Mther Father Grandfather Grandmther Osteprsis / Ostepenia / Decreased Bne Mass Degenerative Disc Disease / Spinal Arthritis / Spinal Stensis Previus Spinal / Neck Surgery (explain) Diabetes Strke / TIA Genetic Disrders (explain) Scial Histry Alchl Tbacc / Smking Recreatinal Drugs Medical Marijuana Medicatins Birth Cntrl Bld Thinner (Cumadin, etc.) NSAID Narctic Pain Medicatin Muscle relaxers Flurquinlnes antibitics ( examples: Cipr, Factive, Levaquin, Avelx, Nrxin, flxin medicatins ) Statin Drugs ( example: Lipitr, atrvastatin, Pravchl, Crestr, Zcr, Lescl, Vytrin, simvastatin, etc.) DSCC 2016

7 Patient Name: Date: / / Symptm 1 Symptm Intake Frm On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 2 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 127 W. Juanita Ave., #110 Mesa, AZ (P) 480/668/1199 (F) 480/668/7300 1

8 Patient Name: Date: / / Symptm 3 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 4 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please describe): What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other (please describe): Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 127 W. Juanita Ave., #110 Mesa, AZ (P) 480/668/1199 (F) 480/668/7300 2

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn