Name Preferred Name First Middle Last Address. Home Phone Cell Phone Carrier. Work Phone Address. Emergency Contact Phone # Relationship

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1 Welcome to our office! Today s / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name Preferred Name First Middle Last Address City State Zip Code Home Phone Cell Phone Carrier Work Phone Address Preferred Contact Method Home Phone Cell Phone Work Phone of Birth / / Age Gender Male Female Race White/Caucasian Black/African American Hispanic Other I choose not to specify Marital Status Single Married Other Spouse s Name # of Children Emergency Contact Phone # Relationship Referred by Employment Status Employed Full-Time Student Part-Time Student Retired Other Occupation Employer Health Information Do you currently take any medications? Yes No Medication Name Frequency Dosage What Condition? Are you allergic to any medications? Yes No If yes, please list know allergies to medications: 1

2 Current Problem Reason for this visit? What level of intensity would you rate your pain? (No Pain) (Severe) Please select all that apply: Achy Burning Cramping Deep Dull Numbness Radiating Sharp Shooting Soreness Stabbing Stiff Throbbing Tightness Tingling What is the frequency of your symptoms? Constant Frequent Intermittent Occasional What makes your symptoms worse? What makes you symptoms better? When did the symptoms start? How did you injure yourself? Have you ever experienced this before? Yes No How does this affect your personal life? (hobbies, sports, etc ) How does this effect your job? (missed days, inability to lift, stand, sit, etc.) What home remedies have you tried? Have you been to another doctor for this problem? Yes No Have you ever been to a Chiropractor before? Yes No Does this affect any of the following tasks? Bathing/Showering Bending Forward Driving Brushing Teeth Bending Left Golfing Drying Hair Bending Right Exercising Combing Hair Carrying Objects Hobbies Cleaning Getting Up From a Chair Home Maintenance Eating Kneeling House Hold Chores Getting In/Out of Bed Leaning Back Mowing Lawn Going to Bathroom Lifting Objects Picking Up Kids Doing Laundry Reaching Playing Sports Preparing Meals Standing Raking Leaves Putting on Pants Stair Stepping Shoveling Snow Putting on Shirt Sitting Sleeping Putting on Shoes Twisting Swimming Taking out Trash Walking Yard Work 2

3 Have you ever.. Yes No Been knocked unconscious? Yes No Been in a car accident? Yes No Been treated for a spine problem/nerve disorder? Yes No Had any significant falls, slips, or injuries? Yes No Fractured/broken a bone? Yes No Had surgery? Yes No Been hospitalized for other than surgery? Last imaging taken (x-ray, MRI, CT)? Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker If yes, how often do you smoke? Current every day smoker Current sometimes smoker # Packs per day If yes, what is your level of interest in quitting smoking? No interest Very Interested Do you consume alcohol? Yes No # Drinks per week Do you consume caffeine? Coffee Soda Tea Energy Drinks # Drinks per day Do you exercise? No Infrequent Occasional Regular What type of exercise? Please mark any you currently have or have had previously: AIDS Cramps Kidney Infections Sciatica Alcoholism Depression Kidney Stone Shortness of Breath Allergies Diabetes Loss of Memory Sinus Infection Anemia Digestions Problems Loss of Balance Sleep Problems/Insomnia Arteriosclerosis Dizziness Loss of Smell Spinal Curvatures Arthritis Excessive Menstruation Loss of Taste Stroke Asthma Eye Pain/Difficulties Migraine Headache Swelling in Ankles Back Pain Fatigue Nervousness Thyroid Condition Bronchitis Headache Nosebleeds Tuberculosis Bruise Easily Hemorrhoids Pacemaker Ulcers Cancer High Blood Pressure Polio Varicose Veins Chest Pain/Conditions Hot Flashes Poor Posture Cold Extremities Irregular Heart Beat Prostate Issues Constipation Irregular Cycle Ringing in Ears Is there a family history of? (Include Relationship) Heart Disease Cancer Stroke Arthritis Diabetes High Blood Pressure Other Women Only Are you pregnant? Yes No Maybe Number of Weeks Estimated Due 3

4 Habits and Lifestyle? Do you sleep on your side, stomach, or back? (circle all that apply) How many hours on average do you sleep a night? How old is your mattress? How Many ounces of water do you drink per day? How many meals on average do you consume a day? Are you on any special diets or dietary restrictions? Current weight? (lbs.) Height? (ft.) Last Blood pressure reading? Are you concerned about your weight? If so, what is your goal weight? (lbs.) The information that I have provided above is accurate to the best of my knowledge and will be used to determine appropriate chiropractic care. Patient Notice of Privacy Practices Our practice is dedicated to maintain the privacy of your health information according to the guidelines set forth by federal and state law. These laws also require us to provide you with notice of privacy practices, and inform you of your rights and our obligations concerning your health information. The undersigned hereby acknowledges that you may receive/review, and understand and agree to the Notice of Privacy Practices, which describes the practice s policies and procedures regarding the use and disclosure of any of my Protected Health Information created, received or maintained by Dr. Brian J Chandler, D.C., Heidi Chandler, LMT and Karen VanderHorst, LMT. / / 4

5 Statement of Informed Consent Chiropractic adjustments are performed in our office by skilled doctors of chiropractic who have successfully completed advanced educational requirements, national board examinations, and state board examinations. As with any healthcare procedure, there are some inherent risks that exist. Whenever possible this risk is minimized to its lowest level. Our doctor, Attitude Adjustments and staff make every effort possible to provide the safest chiropractic care available. Massage and Massage Cupping I understand that all treatment at Attitude Adjustments are therapeutic in nature. I agree to notify the therapist of any physical discomfort or draping issues during the session. I have been provided information on massage cupping. If I choose to experience this therapy in my treatment, I understand the effects and after care recommendations. It has been explained to me that there is the possibility of skin discoloration or Cup Kiss appearing as the tissue is released. I am aware that a Cup Kiss is not a bruise and that it will dissipate within a few hours to a few days. The undersigned hereby consents to evaluation and treatment rendered according to the applicable standards of care. It is understood that options exist for treatment and that any/all treatments have risks and benefits. If the risks and benefits of proposed treatment are not clear to me, I understand that further information may be requested for the doctor. / / Assignment of Benefits Assignment of benefits is simply authorizing Dr., Heidi Chandler, LMT and Karen VanderHorst, LMT to file charges directly to your insurance company, saving you time and effort of filing claims yourself. The undersigned hereby authorizes Dr., Heidi Chandler, LMT, and Karen VanderHorst, LMT to submit my insurance claims to my insurance company. By having my signature on file, I need not sign each claim submitted by their office. I understand that I may withdraw my signature at any time. I also that I am ultimately responsible for all charges for which my insurance does not pay under the contractual agreement. / / 5