WOODLANDS FAMILY CHIROPRACTIC

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We appreciate you choosing our office. Is there anyone we can thank for referring you? Please indicate the main reason you are seeing us today: IF you are seeing us for a PAIN related issue, USE THE SYMBOLS to show the type of pain you feel in each location. Using the PAIN SCALE below, CIRCLE the pain level you experience when your problem is at its WORST:. Is there any RADIATING PAIN into the arms or legs? Any numbness or tingling? How OFTEN do you experience your problem? (Please indicate for EACH SEPARATE LOCATION if applicable)

Constant (75 100% of the time) Frequent (50 75% of the time) Occasional (25 50% of the time) Intermittent (0 25% of the time) List any MD s or other CHIORPRACTORS you ve already seen for this problem: What TESTS have you already had for this problem? X-rays MRI C.T. Scan Myelogram EMG/NCV None Other What REMEDIES have you already tried for this problem that haven t fixed it yet? Anti-inflammatory Pain Meds Muscle Relaxers Injections Physical Therapy Chiropractic Massage Exercise Other What makes your problem WORSE? Sitting Standing Changing Position Walking Bending Lifting Twisting Reaching Driving Sleeping Sneeze/Cough Computer Work Telephone Going From Sit To Stand Other PAST MEDICAL HISTORY Please list any conditions that you ve been DIAGNOSED with or been treated for over the course of your life: Please list any SURGERIES you have had over the course of your life: MEDICATIONS & ALLERGIES Are you ALLERGIC to any medications? Yes No If yes, please list: List any MEDS, HERBS OR SUPPLEMENTS you are taking:

FAMILY HISTORY Mother: Living Deceased List any medical problems: Father: Living Deceased List any medical problems: List any problems COMMON in your family: Cancer Diabetes Heart disease High blood pressure Stroke Arthritis Scoliosis Thyroid disease Osteoporosis SOCIAL HISTORY Marital status: Married Single Divorced Common Law Engaged Widowed Do you have any children? Yes No If yes, how many? _ Do you drink alcohol? Yes No If yes, how much & how often? Do you smoke? Yes No If yes, how much, how often & how long? Do you use any illegal drugs? Yes No If yes, what drugs, how often & how long? Are you currently employed? Yes No If yes, what is your occupation? Who is your current employer? How long have you been at this job? On a scale of 0 to 10 with 0=Worst and 10=Best, rate how well you think you are doing with the following: Exercise Sleep Diet Stress Level Water Intake Energy Level = Do you take: Omega 3 (Fish Oil)? Yes No Vitamin D3? Yes No Probiotics? Yes No REVIEW OF SYSTEMS Please use the scale below (0 to 4) to rate each of the symptoms on this page according to your health status over the past 30 days: 0 = Never have this symptom 1 = Occasionally have this symptom, effect not severe 2 = Occasionally have this symptom, effect is severe 3 = Frequently have this symptom, effect not severe 4 = Frequently have this symptom, effect is severe Head: Headaches Faintness Dizziness Insomnia Energy/Activity: Fatigue/Sluggishness Apapthy/Lethargy Hyperactivity Restlessness Lungs: Chest Congestion Asthma, Bronchitis Shortness Of Breath Difficulty Breathing

Eyes: Watery or Itchy Eyes Swollen, Red or Sticky Eyelids Bags or Dark Circles Under Eyes Blurred or Tunnel Vision (not including near or far sightedness) Ears: Itchy Ears Earaches, Ear Infections Drainage From Ear Ringing In Ears, Hearing Loss Nose: Stuffy Nose Sinus Problems Hay Fever Sneezing Attacks Excessive Mucus Formation Mouth & Throat: Chronic Coughing Frequent Need to Clear Throat Sore Throat, Hoarseness Swollen or Discolored Tongue Canker Sores Skin: Acne Hives, Rashes, Dry Skin Hair Loss Flushing, Hot Flashes Excessive Sweating Weight: Binge Eating/Drinking Craving Certain Foods Excessive Weight Compulsive Eating Water Retention Underweight Emotions: Mood Swings Anxiety/Fear/Nervousness Anger/Irritability/Aggressiveness Depression Mind: Poor Memory Confusion, Poor Comprehension Poor Concentration Poor Physical Condition Difficulty Making Decisions Stuttering or Stammering Slurred speech Joints/Muscles: Pain or Aches in Joints Arthritis Stiffness or Limited Movement Pain or Aches in Muscles Weakness or Fatigued Muscles Heart: Irregular or Skipped Heartbeat Rapid or Pounding Heartbeat Chest Pain Digestive Tract: Nausea, Vomiting Diarrhea Constipation Bloated Feeling Belching, Passing Gas Heartburn Intestinal/Stomach Pain Other: Frequent Illness Frequent or Urgent Urination Genital Itch or Discharge Grand Total: ASSIGNMENT OF BENEFITS & RELEASE OF HEALTHCARE INFORMATION I hereby authorize Keyes to Health, PLLC (KTH) doing business as Woodlands Family Chiropractic (WFC) to release patient healthcare information, compiled from the medical record pertaining to my services, in accordance with the policy of the clinic and Texas law, to facilitate reimbursement by a health benefit plan or third party payor, including but not limited to my insurance carries, Medicare or any other payor or agency. I also hereby authorize for services rendered. I am financially responsible and will pay for charges not covered on my insurance plan.

CONSENT TO TREATMENT I, or authorized representative/legal guardian acting on behalf of the patient, do hereby consent to receiving chiropractic services, which may include routine diagnostic procedures and treatment by the chiropractor, his assistants or designees, considered to be necessary in his judgment. I also acknowledge that the practice of health care is not an exact science and that no guarantees have been made to me as to results of treatment or examination at KTH/WFC. FINANCIAL AGREEMENT & RESPONSIBILITY For and in consideration of services rendered or to be rendered by KTH/WFC, I agree to pay clinic for all services and charges. I understand that I am responsible for any health insurance deductibles, coinsurance and non-covered charges. Payment in full is due at the time services are rendered or payment arrangements are to be made before your appointment. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE--HIPPA I, the undersigned, hereby acknowledge receipt of the Notice of Privacy Practices for this practice. I understand how my healthcare information will be used and disclosed. Patient/Guarantor Signature: Date:

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