Address: City State Zip. Address: Father/Mother/Guardian: Phone:( )

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1 Legal Name: Date: Address: City State Zip Telephone Home ( ) Work ( ) Cell ( ) We use text messaging for appointment reminders. Who is your cell phone company? Address: Preferred Name: Male Female Birth Date: / / If you are under 18 years of age, who are your legal parents or guardian? Father/Mother/Guardian: Phone:( ) Marital Status: Married Single Spouse s Name: Children? Occupation: Employer: Employer Address & Phone #: Student at FULL-TIME PART-TIME Who should we contact in the event of an emergency? _ Phone ( ) Address of contact person Have you seen a Chiropractor before? Yes No If yes, when? Whom may we thank for referring you to our office? Primary Care Physician: Phone ( ) Address: Informed Consent Form Chiropractic is among the safest health disciplines in all of health care. Clinical studies have shown the most common side-effect of joint mobilization and joint manipulation/adjustment is mild, temporary local muscle soreness. The temporary soreness may be similar to what is experienced when beginning a new exercise or physical activity. Other side-effects, including numbness, headache, dizziness, or an increase in pain or symptoms are rare occurrences and should be reported to your chiropractor immediately. It is our office policy that all services rendered are the responsibility of the patient, and that you are ultimately personally responsible for all payments regardless of whether or not this office accepts insurance assignment. Consent to Begin Care I,, do hereby give consent to be treated by the practitioners of this office as they deem necessary. I understand that the treatments may consist of joint mobilizations, joint manipulations/ adjustments, manual muscle therapies, therapeutic exercises and activities, various forms of traction, physiological modalities, ergonomic instruction, lifestyle modifications, and/or nutritional recommendations. I am aware of the possible risks and complications as described previously in this summary. I have read, or have had read to me, the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction prior to my signature. I have made my decision voluntarily and freely. The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation & give consent for treatment. Patient Signature Date Guardian Signature Date

2 YOUR HEALTH SUMMARY Please check all symptoms you have ever had, even if they do not seem related to your current problem. Headaches Pins and Needles in legs Fainting Neck Pain Pins and Needles in arms Loss of smell Back Pain Loss of balance Dizziness Buzzing in ears Ringing in ears Nervousness Numbness in fingers Numbness in toes Loss of taste Stomach upset Fatigue Depression Irritability Tension Sleeping problems Neck stiff Cold hands Cold feet Diarrhea Constipation Fever Hot flashes Cold sweats Lights bother eyes Problem urinating Heartburn Mood swings Menstrual Pain Menstrual irregularity Ulcers List any medications you are taking _ WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? YES NO UNCERTAIN Ehlers Danlos (type IV) Marfan's Disease -Marfan Variant Disorders: Ehlers-Danlos and Marian's Disease are genetic conditions that have been associated with injuries of the joints, connective tissues and blood vessels of the body. Other known, but yet-to-be named, genetic variants exist and are associated with similar risks. Medical studies have reported that blood vessel injuries of the neck known as cervical arterial dissections may occur spontaneously, with trivial traumas of the spine, in patients with high homocysteine levels, and/or during upper respiratory infections particularly in these groups of patients. Have you been told that you have a connective tissue disorder? YES / NO Is your condition or injury due to an accident or work-related cause? YES NO Please check ALL that apply. Did the condition or injury result from automobile accident? YES NO Did it result from a work-related accident or cause? YES NO (briefly describe): If the condition did not result from an automobile accident or relate to your work, where did the accident occur? **If you answered Yes to any of the above questions please see the Front Desk for additional paperwork** Do you have health insurance? YES NO Company: Full Name of Policy Holder: Policy Holder's Date of Birth / / Does the policy holder have the insurance through his/her employer? YES NO If yes, who is the employer?

3 Health Satisfaction Questionnaire Name: Date: Weight Height ft. in. Please answer the questions on a scale of 1 to 1, where 1 indicates I don t agree with the statement And 1 representing that you completely agree with the statement. Physical Health I am a physically fit person and formally exercise on a regular basis. I have a physically attractive body that I am proud to look at in the mirror. I have not had many traumas in my life (auto accident, broken bones, bad falls). I get at least 7 hours of sleep, 7 days at week I have gotten regular Chiropractic care within the past 5 years. Total Emotional/Mental Health I am a calm, peaceful person. I can shut my mind off and focus my mind at will. I practice some form of mental relaxation (meditation, yoga, breathing exercises, prayer, etc.) on a regular basis. Most of the time, I am truly happy and feel a sense of purpose in my life. I have healthy relationships and a rich social network of friends and activities. I am organized, have time for myself, and can prioritize the important tasks in my life. Total Chemical/Nutritional Health I eat 4-6 small meals daily and properly combine my protein, carbs, and fats. I supplement everyday with good supplements such as a vitamin/mineral complex, antioxidants, and good fatty acids (fish oil, flax seeds). I do not take medications for chronic medical problems such as digestive disorders; cardiovascular problems; headaches; chronic pain; blood sugar problems; chronic fatigue; immune problems or chronic infections; or any other chronic conditions. I do not smoke cigarettes. I drink water as my primary beverage and consume at least half my body weight in ounces per day. Total Total of all 3 (physical, emotional, chemical) sections

4 Medical Symptoms Questionnaire Patient Name Date Rate each of the following symptoms based upon your typical health profile for the past 3 days Point Scale - Never or almost never have the symptom 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe HEAD EYES EARS NOSE Headaches Faintness Dizziness Insomnia Watery or Itchy Eyes Swollen, Reddened or Sticky Eyelids Bags or Dark Circles under Eyes Blurred or Tunnel Vision Itchy Ears Earaches, Ear Infections Drainage from Ear Ringing in Ears, Hearing Loss Stuffy Nose Sinus Problems Hay Fever Sneezing Attacks Excessive Mucus Formation DIGESTIVE TRACT Nausea, Vomiting Diarrhea Constipation Belching, Passing Gas Heartburn Intestinal/Stomach Pain JOINTS/MUSCLE Pain or Aches in Joints Arthritis Stiffness or Limitations Pain or Aches in Muscles Feeling of Weakness/Tiredness WEIGHT Binge Eating/Drinking Craving Certain Foods Excessive Weight Compulsive Eating Water Retention Underweight MOUTH/THROAT Chronic Cough Gagging, Frequent Need to Clear Throat Sore Throat, Hoarseness, or Loss of Voice Swollen or Discolored Tongue or Gums Canker Sores SKIN HEART LUNGS Acne Hives, Rashes, Dry Skin Hair Loss Flushing, Hot Flashes Excessive Sweating Irregular or Skipped Heartbeat Rapid or Pounding Heartbeat Chest Pain Chest Congestion Asthma, Bronchitis Shortness of Breath Difficulty Breathing ENERGY/ACTIVITY Fatigue, Sluggishness Apathy, Lethargy Hyperactivity Restlessness MIND Poor Memory Confusion, Poor Comprehension Poor Concentration Poor Physical Condition Difficulty in Making Decisions Stuttering or Stammering Slurred Speech Learning Disabilities EMOTIONS Mood Swings Anxiety, Fear, Nervousness Anger, Irritability, Aggressiveness Depression OTHER Frequent Illness Frequent or Urgent Urination Genital Itch or Discharge

5 8151 Ridge Avenue Philadelphia, PA Ph Fax: Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name : Last Name : address: _@ Preferred method of communication for patient reminders (Circle one): / Phone / Mail DOB: / / Gender (Circle one): Male / Female Preferred Language: Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked CMS requires providers to report both race and ethnicity Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) Native Hawaiian or Pacific Islander / Other / I Decline to Answer Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer Are you currently taking any medications? (Please include regularly used over the counter medications) Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.) Do you have any medication allergies? Medication Name Reaction Onset Date Additional Comments I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.) Patient Signature: Date: For office use only Height: Weight: Blood Pressure: /