CHIROPRACTIC REGISTRATION AND HISTORY. Is Condition due to an accident? 0 Yes 0 No Date. . To whom have you made a report of your accident?

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1 CHROPRACTC REGSTRATON AND HSTORY eft. PATENT NFORMATON -Date SS/HC/Patient 10 #...:- Patient Name -.-::==-=:;:::- Last Name ~~NSURANCE NFORMATON ~ Who is responsible for this account? Relationship to Patient nsurance Co. Group# Address City State Sex OM First Name OF Age Middle nitial ~p Birthdate o Married o Widowed o Single o Minor o Separated o Divorced o Partnered for years Patient EmployerSchool Occupation Employer/School Address Employer/School Phone L---> Spouse's Name Birthdate SS# Spouse's Employer s patient covered by additional insurance? 0 Yes 0 No Subscriber's Name Birthdate SS# Relationship to Patient nsurance Co. Group# ASSGNMENT AND RELEASe certify that, andlor my dependent(s), have nsurance cov~rage n-..,---,...,------, r.,-.,.---- and assign directty to Name of nsurance Company(ies) Or. all insurance benefits, if any~ otherwise payable to me for services rendered. understand that am financially responsible for all charges whether or not paid by insurance. authorize the use of my signature on at nsurance submissions. The above-named doctor may use my health care information and may disclose such nformation to the above-named nsurance Company(ies) and their agents for the purpose of obtaining payment tor services and determining insurance. \ benefits or the benefits payable for related servk;es, This consent will end when my current treatment plan is completed or one year from the date signed below. Signature of Patient, Parent, Guardian or Personal Representative Please print name of Patient, Parent, Guardian or Personal Representative with Whom may we thank for referring you? -,- Date Relationship to Patient Cell Phone L--J Home Phone L--> Best time and place to reach you --'-_ N CASE OF EMERGENCY, CONTACT' Name Relationship _-.: Home Phone L-:J Work Phone, L--> s Condition due to an accident? 0 Yes 0 No Date,Type~f~entOAuto OWork OHome OOther. To whom have you made a report of your accident?, 0 Auto,nsurance 0 Employer 0 Worker Compo 0 Other : Attorney Name. (if applicabl~) Reason for visit: -'- s this condition: Getting worse? Getting better? Staying the same? What makes it worse? VVhatmakesitbetter?

2 ".:, HEALTH HSTORY What treatment have you already received tor your condition? o Medications o Surgery < 0 PhysiCal Therapy o Chiropractic Services DNone DOther Name and address of other doctor(s) who have treated you for your condition Date of Last: PhySical Exam.Spinal X-Ray BloodTest Spinal Exam C~X-Ray Urine Test - Dental X-Ray MR, CT-Scan, Bone Scan Place a mark on "'Yes" or "No- to indicate if you have had any of the following; AOS/HV OVesONo Emphysema OVes.DNo MisQarriage OVesD,NO ~r:let Fever OVesONo Alcoholism OVesONo Epilepsy OVesDNo Mononucleosis 0 Yes 0 No Stroke DVesDNo Allergy Shots Dyes 0 No Fractures OYesDNo Multiple. Suicide Attempt 0 Yes 0 No Anemia DVesDNo Glaucoma OYesDNo Sclerosis DVesONo Thyroid. Anorexia o Yes 0 No Goiter Mumps DVes.DNo DVesONo Problems OVesONo Appendicitis OvesDNo Gonorrhea Osteoporosis OVesDNo Tonsillitis OVesONo DY~ONo Arthritis OVesONo Pacemaker Gout DVesONo OYesDNo Tuberculosis DVesDNo Asthma DVesONo HearfDisease' Parkinson's Tumors. OVesONo DiSease OVesDNo Growths DYesONo Bleeding Mep8titis 'OYesDNo Disorders Pinched Nerve 0 Yes 0 No Typhoid Fever OVesDNo OVesONO Hemia OVesONo Pneumonia DVesONo Ulcers Breast Lump DYesDNo DVesONO Hemiated DiSk 0 VesD No Polio OVesDNo Vaginal Bronchitis OYesDNo Herpes' DvesDNo Prostate.. nfections DYesDNo Bulimia OYesONo HiQh Problem OVesONO Venereal Cancer OYesDNo Cholesterol 'OVesDNo Prosthesis DVesONo Disease 'OVesONo Cataracts DvesDNO. Kidney Disease 0 Yes 0 No Psychiatric Care DY~ D No Whooping Chemical Uver Disease DYes 0 No Cough OVesDNo Rheumatoid Dependency OYesONo Measles DVesONo Arthritis DYesONo 'Other Chicken Pox. DvesDNO '. Migraine. Rheumatic Diabetes OYesONo Headaches DYes 0 No Fever DYes 0 No EXERCSE. WORKACTMTY. HABTS o None o Sitting o Smoking PackslDay, o Moderate o Standing o Alcohol OrinksWeek -- o Daily o UghtLabor o Coffee/Caffeine Drinks CupslOaY'" o Heavy o HEtaVy labor o High Stress Level "Reason -_.. Are you pregnant? o Yes o No DueDate, njuries/surgeries you have had Description Date Falls Head njuries -. Broken Bones Dislocations Surgeries - " MEDCATONS ALLERGES. VTAMNSa RBS' MNERALS Pharmacy Name, -'-- Pharmacy PhOne

3 PAN DRAWNG PATENT NAME PATENT 10 # KEY USE LETERS BELOW TO NDCAT.E TYPE AND LOCATON OF DSCOMFORT A= ACHE B=BURNNG C = STABBNG N=NUMBNG 1 P = PNS & NEEDLES lo=other DATE Mark below on the scale from 0 to 10 your level of pain discomfort with 0 being none and 10 being unbearable. NECK ARM MD BACK LOW BACK LEG o ACTVTES OF DALY LVNG Circle any activity you have a problem with: ST STAND BEND LAY CARRY PUSH PULL REACH RSE LFT WALK SLEEP s there any other daily activity that is currently difficult for you? Revised 9/8/09

4 SYMPTOM SURVEY (Circle As Many As Applicable) GENERAL SYMPTOMS: CHEST: a) Nervousness b) rritability c) Fatigue d) Depression e) Loss of Sleep ~ Tension g) PMS h) Jaw Pain HEAD: a) Headache -- How often? times per (Day / Wk / Month) Are they: Sharp / Dull Are they: Back of Head / Forehead / Temples Right Side / Left Side / Behind Eyes b) Light Headed c) Memory Loss d) Fainting e) Blurred Vision ~ Double Vision g) Sensitivity to Light h) Loss of Balance i) Hearing Loss j) Ringing in Ears NECK: a) Pain -- Pain Level: Stabbing / Dull/ Ache / Burn / Numbness / Pins&Needles b) Stiffness c) Muscle Spasm d) Grinding/Grating Sounds SHOULDERS: a) Pain in Joint -- b) Pain Across Shoulder-- c) Limitation of Movement - d) Tension- ntensity: Frequency: Pain Level: ARMS: Mild / Moderate / Severe Occasional/ntermittent / Frequent / Constant Stabbing / Dull/ Ache / Burn / Numbness / Pins&Needles a) Pain in Upper Arm -- Left / Right! Both b) Pain in Elbow -- c) Pain in Wrist -- d) Pain in Hand -- e) Pain in Forearm -- ~ Pins and Needles (Arm) -- Left / Right! Both g) Pins & Needles (Forearm) -- h) Pins & Needles (Hand) -- i) Numbness: Hand / Arm / Forearm -- a) Deep Chest Pain - ntensity: Frequency: b) Pain Around Ribs -- c) Shortness of Breath ABDOMEN: Mild / Moderate / Severe Occasional/ntermittent / Frequent / Constant d) rregular Heartbeat a) Pain -- Mild / Moderate / Severe b) Nervous Stomach c) Nausea d) Gas e) Constipation ~ Diarrhea g) Heartburn h) ndigestion i) Loss of Appetite LOW BACK: a) Upper Lumbar Pain -- Left / Right! Both b) Lower Lumbar Pain -- c) Sacro-lliac Pain -- d) Muscle Spasm -- Pain Level: Stabbing / Dull/ Ache / Burn / Numbness / Pins&Needles LEGS: a) Pain in Buttocks -- ntensity: Mild / Moderate / Severe b) Pain in Hip Joint - c) Pain Down Leg -- / Front / Back / Side ntensity: Mild / Moderate / Severe d) Numbness Down Leg -- Front / Back / Side e) Pins and Needles (Leg) -- Front! Back / Side ntensity: Frequency: Mild / Moderate / Severe Occasional/ntermittent / Frequent / Constant ~ Knee Pain - g) Leg Cramps -- FEET: MDBACK: a) Upper Midback Pain -- b) Lower Midback Pain -- Pain Level: Stabbing / Dull/ Ache / Burn / Numbness / Pins&Needles c) Muscle Spasm -- a) Ankle Pain -- b) Swollen Ankle-- c) Foot Pain -- d) Numbness of Feet -- e) Swollen Feet- ~ Cramps-- g) Toe Pain-- Left / Right! Both

5 Necklndex ACN GrouP. nc. - Form N-100 ACN GrouP. nc. Use Only rev 11113/02 PaOentName ~ Date., This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. f two or more statements. in one section apply, please mark the one statement that most closely describes your problem. Pain have no pain at the moment. <D The pain is very mild at the moment. (%) The pain comes and goes and is The pain is fairly severe at the The pain is very severe at the The pain is the worst imaginable at the moment. have no trouble sleeping. <D My sleep is slighoy disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours My sleep is completely disturbed (5-7 hours sleepless). can read as much as want with no neck pain. <D can read as much as want with slight neck pain. (%) can read as much as want with moderate neck cannot read as much as want because of moderate neck pain; can hardly read at all because of severe neck pain. cannot read at all because of neck pain. Personal Care (0) can look after myself normally without causing extra pain. <D can look after myself normally but it causes extra pain. (%) t is painful to look after myself and am slow and careful. (3) need some help but manage most of my personal care. need help every day in most aspects of self care. ~ do not get dressed, wash with difficulty and stay in bed.. lifting (0) can lift heavy weights without extra pain. <D can lift heavy weights but it causes extra pain. <2> Pain prevents me from lifting heavy weights off the floor, but can manage if they are convenienoy positioned (e.g., on a table). (3) Pain prevents me from lifting heavy weights off the floor, but can manage light to medium weights if they are conveniently positioned. can only lift very light weights. G> cannot lift or carry anything at au. Driving (0) can drive my car without any neck pain. <D can drive my car as long as want with slight neck pain. <2> can drive my care as long as want with moderate neck pain. (3) cannot drive my car as long as want because of moderate neck pain. can hardly drive at all because of severe neck pain. G> cannot drive my car at all because of neck pain. can concentrate fully when want with no difficulty.. <D can concentrate fully when want with slight difficulty. (%) have a fair degree of difficulty concentrating when have a lot of difficulty concentrating when want. have a great deal of difficulty concentrating when cannot concentrate at all. Recreation (0) am able to engage in all my recreation activities without neck pain. <D am able to engage in all my usual recreation activities with some neck pain. <2> am able to engage in most but not all my usual recreation activities because of neck pain. (3) am only able to engage in a few of my usual recreation activities because of neck pain. can hardly do any recreation activities because of neck pain. ~ cannot do any recreation activities at all. can do as much work as want. <D can only do my usual work but no more. (%) can only do most of my usual work but no cannot do my usual can hardly do any work at cannot do any work at all. Headaches (0) have no headaches at all. <D have slight headaches which come infrequently. <2> have moderate headaches which come infrequently. (3) have moderate headaches which come frequently. have severe headaches which come frequently. ~ have headaches almost all the time. Neck ndex Score

6 Backlndex ACN Group, hie. - Form B-100 ACN Group, nc. Use Only rev Patient Name Date ~~ ~ This questionnaire will give your provider information about how your back condition affects your everyqay life. Please answer every section by marking the onest~tement that applies to you. f two or more statements in one section apply, please mark the one statement that most closely describes your problem. Pain The pain comes and goes and is very mild. G) The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary The pain comes and goes and is very The pain is very severe and does not vary much. get no pain in bed. G) get pain in bed but it does not prevent me from sleeping well. Because of pain my normal sleep is reduced by less than 25%. Because of pain my normal sleep is reduced by less than Because of pain my normal sleep is reduced by less than Pain prevents me from sleeping at all. can sit in any chair as long as like. G) can only sit in my favorite chair as long as like. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than 1/2 Pain prevents me from sitting more than 10 avoid sitting because it increases pain immediately. Personal do not have to change my way of washing or dressing in order to avoid pain. ed do not normally change my way of washing or dressing even though it causes some pain. < Washing and dressing increases the pain but manage not to change my way of doing Washing and dressing increases the pain and find it necessary to change my way of doing it. Because of the pain am unable to do some washing and dressing without Because of the pain am unable to do any washing and dressing without help. can lift heavy weights without extra pain. ed can lift heavy weights but it causes extra pain. < Pain prevents me from lifting heavy weights off the Pain prevents me from lifting heavy weights off the floor, but can manage if they are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights off the floor. but can manage light to medium weights if they are conveniently can only lift very light weights. get no pain while traveling. ed get some pain while traveling but none of my usual forms of travel make it worse. < get extra pain while traveling but it does not cause me to seek altemate forms of get extra pain while traveling which causes me to seek alternate forms of travel. Pain restricts all forms of travel except that done while lying Pain restricts all forms of travel. can stand as long as want without pain. G) have some pain while standing but it does not increase with time. cannot stand for longer than 1 hour without increasing pain. cannot stand for longer than 1/2 hour without increasing cannot stand for longer than 10 minutes without increasing avoid standing because it increases pain immediately. Social My social life is normal and gives me no extra pain. ed My social life is normal but increases the degree of pain. < Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, Pain has restricted my social lite and do not go out very often. Pain has restricted my social life to my have hardly any social life because of the pain. have no pain while walking. G) have some pain while walking but it doesn't increase with distance. cannot walk more than 1 mile without increasing cannot walk more than 1/2 mile without increasing cannot walk more than 1/4 mile without increasing cannot walk at all without increasing pain. Changing degree of My pain is rapidly getting better. ed My pain fluctuates but overall is definitely getting better. < My pain seems to be getting better but improvement is My pain is neither getting better or worse. My pain is gradually My pain is rapidly worsening. ~~~~ " Score ~

7 Anchor Chiropractic Terms of acceptance When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objectives. Chiropractic has only one goal. t is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of the vertebral subluxation. Our chiropractic method of correction is by specific adjustments in the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral subluxation: A misalignment of one or more of the 24 vertebral in the spinal column, which causes alteration of the nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's ability to express it's maximum health potential. We do not offer to a diagnose or treat any disease or condition other then the vertebral subluxation. However if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. f you desire advice, diagnosis or treatment for those findings, we advise you. f you desire advice, diagnosis or treatment for those findings we will recommend that you seek the services of another health care provider. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTCE OBJECTVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxation., have read and fully understand the above statements. (Print name) A" question regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction. therefore accept chiropractic care in this basis. (signature) (date)