Back In Balance Chiropractic, LLC

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Back In Balance Chiropractic, LLC Date Name What do you prefer to be called Address City State Zip Code Birth Date: / / Social Security Number: - - Height: Weight: E-mail Home Phone ( ) - Cell ( ) - Contact Preference: Home Phone Cell Phone Email Postal Mail Emergency Contact: Phone: ( ) - Work status: Working Unemployed Disabled Retired Homemaker Occupation /Employer (current/most recent): Marital Status: Married Single Separated Divorced Widowed Spouse s Name Spouse s Employer Do you have any children? No Yes, How many? Who referred you to our office? Who is your Family Dr. Have you ever been to a chiropractor or acupuncturist before? No Yes Who: Is your visit due to an auto or work related accident? No Yes Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. We invite you to discuss with us any questions regarding our services. The best services are based on a friendly, mutual understanding between provider and patient. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. I have had an opportunity to review the clinics HIPAA policy and have been afforded an opportunity to receive a copy of it and understand that I may ask for one at any time. Printed Name Signature Date

Name: Date: Do you have Allergies? Food Environmental Medication None List type of Allergy and Reaction(s): Medications/ Vitamins/ Supplements (Please list both prescription and non-prescription) None Surgical History: (Please list all previous surgeries, the surgeon and date) None Review of Systems: Please circle any condition you are currently experiencing. Constitutional: Fever Weight loss Weight gain Chills Other Neurologic: Headache Dizziness Memory Loss Numbness Other Eyes: Glasses Contacts Double vision Blurriness Other Ears/Throat: Deafness Ringing Hoarseness Swallowing difficulty Other Cardiac: Chest pain Skip beats Rapid beat Edema/ankle swelling Other Pulmonary: Cough Cough blood Short of breath Wheezing Other Intestinal: Diarrhea Bleeding Incontinence Constipation Other Urinary: Burning Bleeding Incontinence Increased Frequency Other Musculoskeletal: Pain Weakness Arthritis Joint Swelling Cane/walker Other Skin: Bruising Lesions Birth marks Other Hematologic: Bleeding Transfusions Hepatitis Other Psychiatric: Depression Insomnia Fatigued Nervous exhaustion Other Miscellaneous: Metal implants Breast Implants Claustrophobic Other

Family History: Please check any problems that run in your family. Yes No Yes No Yes No AIDS Allergies Anemia Arthritis Asthma Cancer Bone Fracture Cirrhosis/Hepatitis Diabetes Dislocated Joints Multiple Sclerosis Heart Problem HIV/ARC High Blood Pressure Kidney Trouble Spinal Disc Disease Low Blood Pressure Mental/Emotional Difficulty Prostate Trouble Rheumatic Fever STD s Sinus Trouble Epilepsy Thyroid Trouble Tuberculosis Ulcer Polio Scoliosis Diverticulitis Other: Medical History: Do you have or have you had any of the following? Yes No Yes No Yes No AIDS Allergies Anemia Arthritis Asthma Bone Fracture Blood Thinners Cancer Cirrhosis/Hepatitis Gout Hay Fever Heart Problem High Blood Pressure HIV/ARC Kidney Trouble Low Blood Pressure Mental/Emotional Difficulty Scoliosis Sinus Trouble Spinal Disc Disease Thyroid Trouble Tuberculosis Ulcer Polio Epilepsy Diabetes I II Prostate Trouble Dislocated Joints Diverticulitis Rheumatic Fever STD s Other: Social History: Tobacco use: Never Former Smoker Current/Every Day Smoker Current Some Day(s) Smoker If Former Smoker, when did you quit? How many packs/day did you smoke If Current Smoker, how long have you smoked? How many packs/day? Alcohol: Never Rare Social (how much? ) Alcoholic Recovering Alcoholic Drug abuse: Never Currently In the past Caffeine Drinks: Yes None Drinks Per Day: Exercise: None Light Moderate Heavy hours per week Water Intake: glasses per day Sleep: No. of hours per day For Women: Are you taking Birth Control? Yes No Are you nursing? Yes No Are you pregnant? Yes No if so, how many weeks?

Name: Date: What are your complaints? Rate your pain with the following scale: Discomfort 1 2 3 4 5 6 7 8 9 10 Intense When did this condition begin? Please explain what happened? Is your condition getting worse better constant comes and goes Have you found anything to make it better? Have you found anything that makes it worse? Is your condition interfering with your: Work Sleep or Daily routine? If so, how: Has this or something similar happened in the past? Yes No Explain: Treatments have included: No medications, therapy, injections, braces or casts. Physical therapy or exercise Braces Anti-inflammatory meds: Manipulation/chiropractic Massage Cortisone injections, how many? Narcotic meds: Acupuncture Traction Previous doctors seen for this problem: None Doctor Specialty Date Treatments Tests done to evaluate your problem: None Please list date of studies, results, and where study done if known. Plain X-rays MRI/CT EMG/NCV Bone scan Other tests Please circle all affected areas on the body chart:

Back In Balance Chiropractic, LLC Brock Falconer, D.C. INFORMED CONSENT TO TREATMENT The Nature of Chiropractic Treatment: The doctor will use his/ her hands or a mechanical device in order to move your joints. You may feel a click or a pop, and you may feel movement of the joint. Various ancillary procedures such as hot or cold packs, massage, electrical muscle stimulation, ultrasound, traction or therapeutic activities may also be used. Possible Risks: As with any health care procedure, complications are possible following a chiropractic adjustment. Complications could include fractures of bones, muscular strain, ligamentous sprain, dislocation of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries in the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. Probability of Risks Occurring: The risks of complications due to chiropractic treatment have been described as rare, about as often as seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can even be reduced by screening procedures. The probability of adverse reaction to ancillary procedures is also considered rare. Acupuncture: Acupuncture is a generally safe method of treatment, but it may have some side effects, including bruising, soreness, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Other Treatment Options Which Could Be Considered May Include the Following: Over the counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization in conjunction with medical care adds the risks of exposure to virulent communicable diseases in a significant number of cases. Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases. Risks of Remaining Untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult. Unusual Risks: I have had the following unusual risks of my case explained to me: I have read the explanation above of chiropractic treatment and I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and hereby give my full consent to treatment. Printed Name Signature Date

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