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Today s Date: INTRODUCTION PATIENT CASE HISTORY PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Home: Mobile: Mobile Carrier: Work: Email: Gender: M / F Marital Status: Single / Married / Other Social Security #: Date of Birth: Student Status: Full Student / Part Student / Non-Student Employed: Y / N Ethnicity: Hispanic or Latino / Not Hispanic or Latino / Decline Preferred Language: English / Decline / Other: Race: Asian / African American / American Indian or Alaskan Native / Other / Native Hawaii or Pacific Islander / White / Decline *Referred By: (Name): Family / Friend / Co-Worker / Doctor / Other Source EMERGENCY CONTACT INFORMATION Name: (First MI Last) Home: Mobile: Relationship: Child / Parent / Spouse / Other: Primary Care Physician: Doctor s Phone: FINANCIAL INFORMATION Insurance Worker s Comp Self-Pay (Cash) Personal Injury/Auto Other (please explain): PRIMARY INSURANCE Insurance Name: Relation to Insured: Self / Spouse / Parent / Child / Other Insured s Name: Gender: M / F Address: City: State: Zip: Phone: Date of Birth: SECONDARY INSURANCE Insurance Name: Relation to Insured: Self / Spouse / Parent / Child / Other Insured s Name: Gender: M / F Address: City: State: Zip: Phone: Date of Birth: RESPONSIBLE PARTY Who is responsible for payment? Self / Other - (Relationship) Name: (First MI Last) Address: City: State: Zip: Phone: Email: It is Usual and Customary to Pay for Services as Rendered Unless Otherwise Arranged Page 1 of 3

PATIENT CASE HISTORY HISTORY OF CURRENT CONDITION Describe Major Complaint: Describe any Secondary Complaints: Describe WHEN and HOW this began: Grade Intensity/Severity of Complaint: None (0) / Mild (1-2) / Mild-Mod (2-4) / Moderate (4-6) / Mod-Severe (6-8) / Severe (8-10) Quality of the complaint/pain: Sharp / Stabbing / Burning / Achy / Dull / Stiff & Sore / Other: How frequent is the complaint present? Off & On / Constant Does this complaint radiate/shoot to any areas of your body? No / Yes (Describe) Head - Base of Skull / Forehead / Sides-Temple R / L / Both Leg - Hip / Thigh-Knee / Calf / Foot-Toes R / L / Both Arm Across Shoulder / Elbow / Hand-Fingers R / L / Both Other Area: Does anything make the complaint better? Ice / Heat / Rest / Movement / Stretching / OTC / Other: Does anything make the complaint worse? Sit / Stand / Walk / Lying / Sleep / Overuse / Other: Which daily activities are being affected by this condition? (Describe) For this CURRENT condition, have you: Received any other treatment? None / DC / MD / PT / Massage / ER / Other: Where? Had any diagnostic testing? X-rays / MRI / CT / Other: When and Where? HEALTH HISTORY (PLEASE USE THE REVERSE SIDE OF THIS PAGE IF ADDITIONAL SPACE IS NEEDED) Medications and Supplements: Allergies to Medications: Name Reaction Family Health History: N/A List relevant major health problems of First degree relatives: Problem Parent (M or F) Sibling (B or S) Child (S or D) Current Medications & Supplements: Name Dosage Frequency Method Social and Occupational History: Smoking/Tobacco Use: Every Day / Some Days / Former / Never Past Health History: (Please list any past ) Number of Falls in the last 24 months: Injuries? Y or N Surgeries: Date Area of the Body Reason Habit Type Amount Year Started Smoking Tobacco Alcohol Caffeine Rec. Drugs Major Injuries / Traumas / Hospitalizations: Date Describe Education: High School / College Grad. / Post Grad. / Other: Lifestyle Hobbies Recreation Exercise Diet Work Other Describe Page 2 of 3

REVIEW OF SYSTEMS General: (constitutional) Recent Weight Change Fever Fatigue Are you currently experiencing any of these symptoms? (Check all the apply) Many of the following conditions respond to Chiropractic and Acupuncture treatment. Musculoskeletal: Low Back Pain Mid Back Pain Neck Pain Arm Problems Leg Problems Painful Joints Stiff/Swollen Joints Sore/Weak Muscles or Joints Muscle Spasms/Cramps Broken Bones Neurological: Numbness or tingling sensations Loss of Feeling Dizziness or light headed Frequent or Recurrent Headaches Convulsions or seizures Tremors Stroke Mind/Stress: Nervousness Depression Sleep Problems Memory Loss or Confusion Genitourinary: Sexual Difficulty Kidney Stones Burning/Painful Urination Change in force/strain w Urination Frequent Urination Blood in Urine Incontinence or Bed Wetting Gastrointestinal: Loss of Appetite Blood in Stool Change in Bowel Movements Painful Bowel Movements Nausea or Vomiting Abdominal Pain Frequent Diarrhea Constipation Cardiovascular & Heart: Chest Pains Rapid or Heartbeat changes Blood Pressure Problems Swelling of Hands, Ankles, or Feet Heart Problems Respiratory: Difficulty Breathing Persistent Cough Coughing Blood Asthma or Wheezing Lung Problems Other: Eyes and Vision: Wear contacts/glasses Blurred or double vision Glaucoma Eye disease or injury Ears, Nose and Throat: Bleeding gums / mouth sores Bad Breath or bad taste Dental Problems Swollen throat or voice change Swollen glands in neck Ringing in the ears Ear - Ache/Ringing/Drainage Sinus / Allergy problems Nose Bleeds Hearing Loss Endocrine, Hematologic, and Lymphatic: Thyroid problems Diabetes Excessive Thirst or urination Cold Extremities Heat or Cold intolerance Change in hat or glove size Dry skin Glandular or hormone problem Swollen Glands Anemia Easily Bruise or Bleed Phlebitis Transfusion Immune system disorder Skin and Breasts: Rash or Itching Change in Skin Color Change in hair or nails Non-healing sores Change of appearance of a mole Breast Pain Breast Lump Breast Discharge Women Only: Are you pregnant? Yes - Due Date / / No - Last Menstrual Period / / Infertility Painful or Irregular periods Vaginal Discharge Pregnancies: Date Outcome Comments: I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with chiropractic care, diagnostic testing, and/or therapeutic services, in accordance with this state's statutes. Patient or Guardian Signature Date Treating Doctor Signature Date Page 3 of 3

Informed Consent and Permission Form When you give your permission to have chiropractic spinal adjustments and physical medicine modalities performed, you or your guardian should understand the most common risks and hazards we are required to disclose of these procedures. These are all rather infrequent but may occur: 1. Post treatment discomfort, or soreness or stiffness, which may persist 12 to 24 hours after treatment. 2. Transient lightheadedness or dizziness following chiropractic adjustments of the neck. Please alert Dr. Snyder should this reaction occur. 3. Aggravation of acute intervertebral disc bulge or herniation. Please be advised that Dr. Snyder will make reasonable efforts to determine the possibility of an underlying disc problem and modify your treatment recommendations accordingly. 4. Spontaneous vertebral body or rib fracture in an osteoporotic patient. Please be advised that Dr. Snyder will make every reasonable effort to diagnose this preexisting condition and modify your treatment recommendations accordingly. 5. Acute onset of muscle spasms alongside the spine in the area being treated or in an adjacent area. These muscle spasm reactions are commonly present, even before treatment, in the acute patient and every effort will be made to reduce them prior to spinal adjustments. I understand that no guarantee had been made and that the procedures may not cure my condition. Authorization To Release Information: Assignment of Benefits I hereby authorize assignee to release information, or grant release from other parties solely related to my health and treatment, to secure payment for my care at this facility and act as my legal representative regarding any matters, including appeals, relating to health care received at this office or medical bills incurred at this office. I hereby assign payment of my benefits, including major medical benefits to which I am entitled, private insurance or any other health plan to: Dr. Justin G. Snyder D.C. 4146 S. Harvard Ave. Suite F-5 Tulsa, OK 74135 I also request insurance payments be sent direct to his office and NOT to the policy holders address. A photocopy of this assignment is to be considered as valid as an original. This assignment remains in effect until revoked by me in writing. I understand that I am financially responsible for all charges whether or not paid by insurance. If the account is placed in collections, additional charges equal to the cost of collections including agency and attorney fees and court cost incurred and permitted by law governing these transactions will be added to the amount due. These services and this agreement were entered into the City of Tulsa. Date Signature Printed Name DOCTOR'S STATEMENT: The patient (guardian) and I have discussed the procedures to be preformed. To the best of my knowledge, the patient (guardian) understands the procedures and consents to it. Dr. Justin G. Snyder D.C.

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