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Dr. Gerard Rosney Dr. Joseph Rosney New Patient Health Information Form Date: Name: DOB: Age: Sex: M / F Home Phone # Cell # Work # Address: City: State: Zip: Email: Marital Status: M / S / D / W Children: Y / N Ages: Who may we thank for referring you? Your hobbies: Do you exercise? Y / N How often? What type? Diet: Healthy / Ave / Poor Vitamins/supplements? Y / N Alcohol: Never/Rare/Moderate/Daily Have you consumed alcohol in the last 24 hours: Y / N When? Smoker: Y / N Packs per day: How Long: Past Smoker Y / N Date Quit: Occupation: Employer: Insurance Company: Policy #: Spouse s name: Spouse s DOB: Occupation: Employer: Insurance Company: Policy # Treatment and Finances: First and foremost the priority in this office is to provide the highest quality of care to all patients. As a courtesy our office will provide each patient with a detailed invoice that can be submitted to insurance for reimbursement directly from your insurance company to you. Please be sure to let us know if you would like an invoice. Though we are happy to provide you with this, it is our policy to collect payment in the office at the time of service. I understand that payment is due at time of service and as a courtesy this office will provide me with a detailed invoice that may be submitted to my insurance company. I have questions about this policy or have other financial related concerns and would like to speak to someone in the office about this.

As a society we are ranked 50th in the world when it comes to health, but at TLC Chiropractic Wellness Center we take pride in helping people to reach their optimum health and wellness. In order to help you best, we would like an honest assessment of where you believe your current level of health is. So please place an X on the scale below marking where you believe your level of health and wellness is at this time. Then place a circle O on the diagram indicating where you would like your health and wellness to be. Very Poor Challenged Less Than Ideal Generally Good Ideal Health Patient Health Profile What brings you into our office? Please briefly describe your chief concern, including the impact it has had on your life. If you have no symptoms or concerns and are here for Chiropractic Wellness Services, please skip to the General History page. Primary Health Concern: When did your health challenge start? Is it getting worse? Yes / No How often are you in pain? _ Is it constant? Yes / No Rate the severity of your pain on a scale from 1 (least) to 10 (severe): Current Today Worst Ever Average Type of pain: (circle all that apply) Sharp / Dull / Throbbing / Numbness / Aching / Shooting / Burning / Tingling Cramps / Stiffness / Swelling / Other: Does it interfere with Work / Sleep / Daily Routine / Recreation Activities that make problems worse: Sitting / Standing / Walking / Bending / Lying Down / Activities that make problems better: Have you received any other type of treatment for this health concern? Y / N If Yes, was the cause of your health concern identified? Y / N If Yes, what was the recommended course of care? Have you had previous chiropractic wellness care? Y / N Details: Please mark your areas of pain on the diagram on the left. Worst Pain Possible Please mark a X at the level of your pain on the scale to the right. No Pain

General History Given that all prescription medications have side effects, some very serious, please tell us what prescription or over the counter medications you are currently taking and why. Supplements are becoming more popular these days as people are looking for more natural ways to manage their own health and wellbeing. Please tell us what supplements you are taking and why. List any traumatic injuries or car accidents: List any doctors you are currently seeing List all surgeries/hospitalizations and dates: Do you have any of the symptoms below today? Sunburn Swelling Headache Cold / Flu Open Cuts, Bruises, Burns Irritated Skin Rash Poison Ivy Slips and falls, although common have a direct impact on your health and wellbeing. Even MINOR falls or accidents can cause long term stress, strain and damage to the spine. In addition to the traumatic injuries listed above, please list any additional slips, falls, etc that you can recall, even if minor. The doctor of the future will give no medication, but will interest his patients in the care of the human frame, diet and in the cause and prevention of disease. Thomas Edison Life is not merely to be alive, but to be well. Marcus Valerius Martial

Health Concerns Checklist Please indicate on the list below, C for current or P for past. Because the Nervous system controls everything in your body, it is common that current health challenges can be related to the problems you are seeking care for in our office. Please indicate if you currently have or have had any of the following symptoms or health conditions. AIDS/HIV Dizziness Loss Alcoholism Allergies Emphysema Anemia Epilepsy Anorexia Fainting Appendicitis Fatigue Arthritis Asthma Fractures Glaucoma Back Pain Goiter Bleeding Disorders Headaches Breast Lump Bronchitis Heartburn Bulimia Heart Disease Cancer Hepatitis Hernia Chemical Dependence Herniated Disk High Constipation Cold Hands Cold Feet Cold Sweats Chicken Pox Depression/Anxiety Blood Pressure High Cholesterol Hot Flashes Irritability Kidney Disease Lights of Smell Loss of Taste Measles Menstrual Pain Menstrual Irregularity Miscarriage Sclerosis Mononucleosis Multiple Mumps Neck Stiffness/Pain Nervousness Numbness in Arms Numbness in Fingers Numbness in Hands Numbness in Legs Numbness in Toes Osteoporosis Pacemaker Parkinson s Pinched Nerve Pneumonia Problem Prosthesis Psychiatric Care Rheumatoid Arthritis Rheumatic Ringing in the ears Scarlet Sleeping Problems STD Attempt Stroke Suicide Tension Thyroid Problems Tonsillitis Tuberculosis Tumors/Cysts Typhoid Ulcer Upset Stomach Urinary Tract Inf. Vaginal Infection Whooping Cough Diabetes Bother Eyes Liver Disease Diarrhea Polio Loss of Balance Prostate If you have any additional health concerns not listed above, please indicate below: FAMILY Health History Please mark below any conditions that apply to your FAMILY health history. High Blood Pressure Heart Disease Emphysema Diabetes Kidney Asthma Seizures HIV Positive Disease Headaches Circulation Back Problems Cancer Ulcer / Stomach Problems Osteoporosis Illness Arthritis Mental Problems

Lifestyle Questions It has been shown that daily lifestyle stress significantly impacts your overall health and wellbeing. As a family wellness office we specialize in not only addressing the cause of your health challenges, but we also focus on teaching you how to manage the lifestyle stresses that are keeping you from reaching your optimum health and wellness. Please rate the following and circle ALL answers that apply to your habits: (1 being very poor and 10 being excellent) Eating Habits A. I eat 35x s a day B. I eat fruits and vegetables daily C. I eat out 23 times weekly (min) D. I drink 35 sodas weekly E. I crave sweets F. I don t watch what I eat Sleep A. I sleep 79 Hours a night B. I wake up well rested C. I wake up tired D. I toss and turn E. I stay up late Exercise Habits A. I exercise 35 times a week B. I walk daily C. I don t exercise D. I want to exercise E. I sit (at a computer) 68 hours a day Mind Set A. I have a positive outlook B. I am generally in a good mood C. I share my feeling easily D. I have a negative outlook E. I am generally in a bad mood F. I bottle things up inside General Health A. I am not on medication B. I take care of myself C. I watch what I eat D. I base my health on what everyone around me is doing E. I think I am healthy but know I could make some changes to be even healthier On a scale of 010 please describe your levels of stress in the following categories of health: (0= none / 10=extreme) Occupational Social Emotional Spiritual Physical Mental Environmental You re Almost There Thank you for providing us with the information that can help us to better serve you and help you to be in the best health you can be!

Health Goals At our office we pride ourselves in helping you to achieve phenomenal results with your health and wellness. In order for us to truly help you to be as healthy as possibly, it is important that we understand your goals for your overall health and wellbeing. Please list your goals for your health and wellness in the spaces provided. Physical Goals Nutrition Goal Stress / Emotional Goals How can we help you? It is our goal with every patient that they might live a LONGER, HAPPIER, and HEALTHIER life in some way as a result of the care, education, and inspiration they receive in this office. Though this is our desire, we want to know how you feel. Please answer the following questions. If we find that there is a need for you to make dietary changes, would you like our recommendations? Yes No If we find that there is a need for you to begin general or specific exercises would you like our recommendations? Yes No If we find there is a need to address emotional or physical stress in your life, would you like our recommendations? Yes No On a scale of 110, with 10 being the highest, how much do you want to get rid of your health problems and move toward wellness, so that you can function better and feel great? Assuming that we could help you with your conditions or health concerns, is there anything that would prevent you from following through with a treatment plan? Yes No At TLC Chiropractic we are always here to answer any questions you have about your health or your care at our office. If you have any questions or concerns now, please specify below. Thank you for taking the time to complete all the information necessary to assess you health concerns and goals so we can begin to help you along the path to wellness! I consent to a complete chiropractic examination and any other diagnostic testing that the doctor deems necessary. I understand the doctor will do their best to explain as much as possible about procedures pertaining to testing and care, and that if I have questions at any time I will ask. Signature Date

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