DEAN S CHIROPRACTIC CENTER

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PATIENT INFORMATION Welcome to Our Office Patient Name of Birth SS# Address City ST Zip Home Phone Cell Work Phone Male Female Email Address Single Married Divorced Widowed Employer Name Occupation Spouse s Name of Birth SS# Spouse s Employer Occupation Emergency Contact Name Phone Relationship How were you referred to us? INSURANCE INFORMATION Insurance Name Relationship to Insured Self Spouse Child (Insured) Cardholder s Name of Birth ID# Group # Yearly Deductible $ **AUTO INSURANCE/ WORKERS COMP ONLY** Insurance Name Policy# Claim# Accident Police Report Yes No Adjuster s Name Adjuster s Phone Fax Claim Address City ST Zip ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with the insurance company listed above and assign directly to Dean s Chiropractic Center, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I herby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION I acknowledge that I have received or have declined a copy of Dean s Chiropractic Center Notice of Privacy Practices for protected health information. X Patient / Guardian Signature X

PATIENT HEALTH HISTORY Patient Name Primary Care Doctor: Previous Chiropractor: Location: When was your last visit? NONE MEDICATIONS NAME DOSAGE What are you taking it for? How long have you been on this? NONE VITAMINS AND SUPPLEMENTS NAME DOSAGE What are you taking it for? How long have you been on this? NONE LIST SURGERIES NONE INJURIES /AUTO ACCIDENTS ETC.. TYPE WHEN TYPE WHEN HEALTH AND SOCIAL HABITS How many glasses of water per day Coffee Intake How many cups per day Soda Intake How many cans/bottles per day Smoking How many packs per day Alcohol How many drinks per week How many children High Stress Level (Reason) Quality of Sleep Excellent Good Poor Sleeping Position Back Stomach Side If you sleep on side, which side: Left Right Describe Diet Excellent Good Poor Exercise Level Excellent Good Poor Work Duties Sitting Standing Lifting What is your occupation: Family History of: Thyroid Heart Disease Diabetes Cancer Other: Anything else not listed you want your doctor to know:

Name: Check the boxes that apply to you. REVIEW OF SYSTEMS None I have reviewed this entire page and NONE of the following conditions listed below apply to me. None CONSTITUTIONAL Past Now None CARDIOVASCULAR Past Now None CONDITIONS Past Now Lack of Energy Heart Disease Alcoholism Unexplained Weight gain Shortness of Breath AIDS/ HIV Unexplained Weight loss Heart Palpitations Anemia Diagnosis of Cancer Heart Murmur Anxiety Ankle Swelling Asthma None EENT Past Now Chest Pain Arthritis Frequent Sinus Infections Pain in Legs with Walking High Blood Pressure Frequent Colds Low Blood Pressure Deafness None RESPIRATORY Past Now High Cholesterol Earaches Chronic Cough Cancer Chronic Sinus Infections Difficulty Breathing Diabetes Type 2 Ringing in Ears Wheezing Diabetes Type 1 Swallowing Problems Diverticulitis None ENDOCRINE Past Now Depression None GASTROINTESTINAL Past Now Excessive Thirst Eczema Gallbladder Problems Low Blood Sugar (hypoglycemia) Epilepsy Constipation High Blood Sugar (hyperglycemia) GERD Diarrhea Shortness of Breath Heartburn Indigestion Adrenal Dysfunction Hiatal Hernia Excessive Hunger Unexplained Hair Loss Hemorrhoids Poor Appetite Excessive Fatigue Heart Attack Heart Murmur None PSYCHIATRIC Past Now None GENITO-URINARY / LIVER Past Now Herpes Frequent Sadness Frequent Bladder Infections Hepatitis A B C Mood Swings Kidney Stones Irritable Bowel Syndrome Suicidal Thoughts Painful Urination Inguinal Hernia Phobias/ Unexplained Fears Mitral Valve Prolapse None MUSCULOSKELETAL Past Now Osteoporosis None SKIN Past Now Arthritis Pneumonia Bruise Easily Hernia Rheumatoid Arthritis Very Dry Skin TMJ (Jaw Pain) Stroke Hives / Rash Bursitis Thyroid - Hypothyroid Itching Joint Swelling Thyroid - Hyperthyroid Varicose Veins Ulcers Skin boils or Lesions None FEMALES ONLY Past Now Anything else not listed: Hot Flashes None NEUROLOGIC Past Now Excessive Menstrual Flow None ALLERGIES Past Now Frequent Headaches Headaches around Menses Seasonal Tremors / Hands shaking Breast Pain Latex Stroke Fibroids Penicillin Seizures / Convulsions Frequent Yeast Infections Sulfa Drugs Double Vision Excessive Fatigue Bee Stings Problems with Balance Lack of Sex Drive Other: Patient Initials

Complaint Form Patient Mark (X) on the body diagram all the areas you have pain or symptoms List complaints in order of severity. 1 Complaint 2 Complaint 3 Complaint 4 Complaint X Patient / Guardian Signature X

INFORMED CONSENT TO CHIROPRACTIC TREATMENT I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination tests, diagnostic x-ray(s) and physical therapy techniques, on me (or on the patient named below for which I am legally responsible) which are recommended by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for or associated with, or serving as back-up for the doctor of chiropractic named below. I understand that, as with any health care procedure, there are certain complications, which may arise during a chiropractic adjustment. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Homers syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, and are in my best interest. I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed. I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and I have decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment. Name and Address of Office Dean s Chiropractic Center, LLC 1225 S. Main St. Suite 201 Greensburg PA 15601 Print Name(s) of Doctor(s) Treating this Patient Dr. Rhonda M. Dean, D.C. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. Printed name of Patient X Signature of Patient or Representative (if minor or physically incapacitated) Witness to Patients Signature

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGMENT I understand that, under the Health Insurance Portability & Accountability Act of 1998 ( HIPAA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment or payment health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name X (Printed) Signature X X Relationship to Patient: Self Parent OFFICE USE ONLY I attempted to obtain the patient s signature in acknowledgment on the Notice of Privacy Practices Acknowledgment, but was unable to do so as documented below: : Initials: Reason:

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