Matthews Family Chiropractic

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Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age: Birthdate: Marital Status: M S W D Number of Children: Names of Children: Occupation: Employer: Primary Phone #: Mobile #: Mobile Service Provider: Email Address: Name of Spouse or Guardian: Cell Phone #: Occupation: Employer: Name of Nearest Relative NOT Living With You: Phone #: Referred By: Date of Last Physical Exam: If you have ever suffered from the following symptoms or do so currently, please check the appropriate box ("P" = in the past, "C" = currently): P C P C P C Fractured bones I Neck Pain or Stiffness Numbness, Tingling, Pain in Auto Accidents R L Buttocks, Legs, Feet, Toes 0-1 years ago Numbness, Tingling, Pain in R LI I 1-5 years ago Arms, Hands, Fingers Foot Trouble I 5 years or more R L Chest Pain, Asthma Other accidents, falls I Jaw Pain or Click (TMJ) Heart Problems I Arthritis R L Stroke I Diabetes Difficulty in Excessive Standing, High/Low Blood Pressure Convulsions, Epilepsy Sitting, Riding, Bending, Lifting, Varicose Veins Skin Problems Twisting Liver Trouble I Cancer Shoulder Pain R LI I Gall Bladder Trouble Frequent Colds, Flu Dizziness II Digestive Problems I I Depressed Ringing in Ears R L Ulcers I Irritable I Hearing Loss Hemorrhoids I Anemia I Blurred or Double Vision Prostate Problems Allergy, Sinus I I Upper Back Pain, Stiffness Impotence Under Stress I I Mid Back Pain, Stiffness Kidney Trouble I Eating Disorders I I Lower Back Pain/Stiffness Menstrual Problems, PMS I I Trouble Sleeping I I Pain with Cough, Sneeze Bedwetting I I Trouble Concentrating I Hip Pain R L Ear Infections Learning Disability I Headaches AIDS, HIV Mood Changes

Matthews Family Chiropractic Dr. John J. Hanna, Director Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 Page 2 Previous Chiropractic Care? I Yes I No Chiropractor's Name: What was the reason for your initial visit? What spinal maintenance programs were you given to follow to maximize the future stability of your spine? Did you follow it? If not, why? Why are you changing chiropractors? Have you been treated for any health condition by a physician in the last year? Describe: What surgeries have you had? List drugs you now take (prescription and non-prescription): What are your health goals? How do you expect to achieve these goals? PAYMENT IS EXPECTED AT TIME OF VISIT! Name of person responsible for payment: Method of payment you plan to use to take care of today's charges: Cash Check Visa/Mastercard Amex Are you insured? ( ) Yes ( ) No Company Name: *Please show all I.D. Cards to the receptionist. RELEASE AND ASSIGNMENT I authorize release of any information necessary to process my insurance claims and assign and request payment directly to my physician. Patient's Signature: Date: I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Matthews Family Chiropractic will prepare any necessary reports and forms as a courtesy to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Matthews Family Chiropractic will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me regardless of insurance, and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to collect this account. I authorize Matthews Family Chiropractic to obtain a credit report if deemed necessary. Patient or Guardian Signature: Card #: Date: Expiration Date:

Prior to answering the following questions, please read the pamphlet entitled "Subluxation" on the last page. Page 3 Patient: Date: PATIENT HISTORY 1. What is your main complaint? 2. Vertebral Subluxations can cause irritation to different fibers within nerves. On the scale below, please circle the severity of your main complaint (at its worst)" None Slight Mild Moderate Severe 1 2 3 4 5 6 7 8 9 10 3. Subluxations can put pressure on the spinal cord which can be constant or occasional. On the scale below, please circle the percentage of time you experience your main complaint: Occasional Intermittent Frequent Constant 0 10 20 30 40 50 60 70 80 90 100 % 4. How long have you been experiencing your main complaint? Date of onset: 5. On the diagram below, please show where you are experiencing all of your present complaints using the following letters: A: Ache B: Burning Pain C: Cramping D: Dull Pain R: Throbbing Pain N: Numbness T: Tingling S: Sharp Do you have pain and/or difficulty performing any of the following activities: (Check) Personal Care Lifting Reading 6. Pressure on the spinal cord or nerves can be worse in the AM or PM. When do you notice it most? I AM I PM How long does it last? Mins Hrs. 7. What makes it feel better? 8. What makes it feel worse? 9. Have you ever had this problem in the past? I Yes I No 10. I have I been hospitalized I been treated by another chiropractor I been treated by another specialty provider I never received care for this problem (Drs. names: ) 11. Have you lost time from work because of it? I Yes I No Dates: to 12. Are you pregnant? I Yes I No 13. What was the first day of your last menstrual cycle? 14. Number of pregnancies? Miscarriages? Concentrating Work Driving Sleeping Recreation Walking Sitting Standing Social Life Signature: Date: / /

IF YOURS IS AN ACCIDENTAL INJURY, PLEASE COMPLETE THE FOLLOWING QUESTIONS Page 4 Date of Accident: Hour AM PM Location How did accident occur? I Auto Collision I On-the-Job Injury I Other If not an auto collision, please describe the circumstances: Did you report the injury to your foreman or employer? I Yes I No Did he (they) recommend care at our office? I Yes I No If an auto accident, were you: I Driver I Passenger I Pedestrian If auto collision, were you struck from: I Behind I Right Side I Left Side I Front I Auto was parked Did your car strike the other(s) involved? I Yes I No OR did the other car strike yours? I Yes I No I Undetermined As a result of the accident, were traffic citations issued to you? I Yes I No To the driver of the other car? I Yes I No To the driver of your car? I Yes I No List the extent of the injuries as you know them: Did you require post-accident hospitalization? I Yes I No Check symptoms you have noticed since the accident: I Headache I Dizziness ILight Bothers Eyes IDiarrhea I Neck Pain I Neck Stiff I Sleeping Problems I Back Pain I Nervousness I Tension IIrritability Chest Pain I Head Seems Too Heavy IPins and Needles in Arms I Pins and Needles in Legs I Numbness in Fingers I Numbness in Toes I Shortness of Breath I Fatigue I Depression ILoss of Memory IEars Ring Face Flushed Buzzing in Ears Loss of Balance IFainting ILoss of Smell I Loss of Taste IFeet Cold IHands Cold IStomach Upset Constipation I Cold Sweats Fever Symptoms other than above: Have you lost any days of work? I Yes I No Dates Insurance Companies Involved: My Company: Company of person responsible for injuries: Have you been contacted by an insurance adjuster or company representative regarding this claim? I Yes I No

INFORMED CONSENT FOR CHIROPRACTIC TREATMENT I (we) hereby request consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy, and if necessary, diagnostic x-rays on me (or the patient names below, for whom I am legally responsible: ), by the chiropractic physician and/or anyone working in this office authorized by the chiropractic physician. I further understand that such chiropractic services may be performed by the Physician of Chiropractic, Dr, John Hanna and/or other licensed Physicians of Chiropractic who may treat me now or in the future at this office. I have had an opportunity to discuss with Dr. John Hanna and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment; including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the physician to be able to anticipate and explain all risks and complications. Further, I wish to rely on the physician to exercise judgment during the course of the procedures which the physician feels are in my best interests at the time, based upon the facts then known. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any conditions(s) for which I seek treatment at this facility. Female Patients: By my signature on this form, I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. To be completed by the patient: To be completed by the patient s representative, if necessary, (e.g. if the patient is a minor or is physically or mentally incapacitated): Patient s Name (Print) Signature of Patient Date Print Name of Representative Relationship/authority if not signed by Patient Date

SUBLUXATION How abnormal position of the spine and subluxation (misalignment) can affect your health Subluxation: 1. A misaligned spinal bone (vertebrae) which causes compression, tension, irritation, and damage to the Central Nervous System [The Central Nervous System is made up of the brain, spinal cord, and spinal nerves. The Central Nervous System totally controls all functions and healing in the human body]. 2. Causes interference of the Central Nerve System. 3. Causes the organs and muscles of the body to malfunction and heal poorly due to the interference they create in the Central Nervous System. Malfunction in the body and poor healing result in lowered resistance to infection, allergies, illness, and disease. SUBLUXATIONS are caused by a lifetime of stress and trauma. Slips, falls, auto accidents, sports injuries, poor posture, bad sleeping habits, stress at work, or even childhood mishaps and the birth process itself can cause the spinal cord to move out of its normal position. The Central Nervous System totally controls all the functions and healing in the body. The most common and likely way to interfere with the Central Nervous System is any abnormal position of the spine or SUBLUXATION (misalignment). Symptoms are the body s warning signals that something has been malfunctioning for some time and has needed attention. In most cases, SUBLUXATION is present without symptom or warning. Usually, SUBLUXATION has existed for many years by the time a symptom arrives. The purpose of a Chiropractic evaluation in our office is to find out if SUBLUXATION is interfering with your Central Nervous System causing malfunction. If we find SUBLUXATION on your exam, nerve tests, and/or x- rays studies WE CAN HELP YOU!

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