What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux)

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What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux) What previous methods have you tried to alleviate your discomfort and did they help at all? Have you consulted another physician for this problem? yes no Name: Did they help? yes no List your major car accidents, falls, and injuries. Give dates List your major diseases. Give dates List any type of surgery or major dental work. Give dates Do you have sufficient energy for your normal activities? Any other symptoms or problems you think the doctor should know? What is your program of regular physical exercise or activity? Have you recently (in the last year) experienced any of the following? Death of a loved one Divorce or separation/marital problems Serious injury or illness of a family member Marriage Loss of a job/extreme job stress Change of a job Retirement Pregnancy or birth of a child Sexual problems Change of financial status Revision of personal habits Change of living conditions Other extreme stress Women: Do you experience the following? Menstrual problems Excessive flow Cramping Pre-menstrual depression Post-menstrual depression Painful breasts Hot flashes Menopause Are you pregnant now? Date of last menstrual period How many days do you menstruate?

Please check the following that apply: Does your work or daily activity include: Do you: Exposure to fumes Grind your teeth? Night Day Exposure to chemicals Clench your teeth? Night Day Mental stress Bruise easily? Physical stress Have Silver/Mercury Fillings? Sitting at a desk Working on hands and knees Do you sleep: Standing for long periods on your stomach? Bending on your back? Lifting on your side? Working overhead Tire easily Exhausted Difficulty staying awake during the day or early evening Nervous Tense Worry easily Been told you are neurotic or trouble was all mental, advised to consult a counselor Crave sweets Lightheaded (black out) Hay fever Asthma Hives Eyes extremely sensitive to light Difficulty getting to sleep Muscle cramps Disposition good Check the following that apply: Have different kinds of headaches How many days of the month do you have headaches? Headaches reoccur at regular intervals Pain makes you get out of bed Had a severe neck injury Unconscious after this injury Instability or unsteadiness associated with posture Mental confusion or forgetfulness Sneezing with temperature change Skin itch Trouble with nails or hair Appetite good Hearing impairment Ear noise - ring Skin dry Faint or become unconscious Cough Stomach ulcers Gums bleed Other stomach trouble Sinus trouble Colitis Short of breath on mild exertion Gas or burp after eating / acid reflux Rheumatoid arthritis Indigestion Lower limbs swell Pain or tight feeling in chest or heart region Cold feet Heart symptoms Feet numb right left Heart beats rapidly and feels shaky Feet tingle right left when not exercising Hands numb right left Vision going bad in either eye Hands tingle right left Lost weight recently Gained weight recently Smoke how many daily: Dizzy spells (room spins) Cigarettes Cigar Pipe Chew Stiff neck One side of head hurts worse than the other Drink alcoholic beverages: Know when going to have a headache How often? Headaches apt to occur on certain days What? of the week or month Know any cause for headaches (i.e. foods, worry, time of month, weather, etc.)

List food that you would typically eat for: Breakfast: Lunch: Dinner: How Many: # of cups of coffee per day? Tea # of glasses of milk per day? # of bottles/cans of juice per day? # of bottles/cans of pop per day? # of glasses of water per day? city well filtered Bowel movements per day? Hours of sleep per night? wake rested? tired? Snacks: Any food allergies? To what? Any drug allergies? To what? Any environmental allergies? To what? Choose one answer: I remember important things in my life by: What I see (visual). What I hear (auditory). What I feel (kinesthetic). Please check the type of care desired: Only temporary relief of symptoms (patch it) Lasting correction / overall health (cause / fix it) On a scale from (0 10) place where you are: (No pain/problem) 0 10 excruciating/discomfort/pain (None) 0 10 motivation to change (I am ready now). Patient Payment Policy 1. Patients are expected to take care of their fees as services are rendered. 2. Patients, who carry health insurance other than Blue Cross/Blue Shield, should remember that services are rendered and charged to the patient and not to the insurance company. We do participate with traditional Blue Cross. Patients are expected to pay their co-pay and deductible at each visit. 3. Our Super Bill has sufficient information to be directly attached to the claim form provided by your insurance carrier. If you have questions or problems, we will of course assist you. 4. We do not participate with Medicare. We are, however, required to bill Medicare directly for your reimbursement. While we will take care of the billings, all payments, denials, etc. will be sent directly to you. 5. For Non-insurance patients, we offer a multi-visit package discount. Ask the front desk person for the program that might help meet your needs. I have read the above and agree to be financially responsible for all changes at this office including my insurance deductibles, co-payment and any services rejected by my insurance company. (If you are unable to meet the above financial obligation, special arrangements must be discussed with the Office Manager. Patient s Signature Date

Identifying Beliefs to Change My Top Three goals in life are: 1. 2. 3. To Achieve these life goals, I need to BELIEVE: 1. 2. 3. Physical/Health Challenges (e.g.: back/neck/arm pain, headaches, weight, energy, sleep, disease) Emotional Challenges (e.g.:grief, stress, fears, phobias, anger, assertiveness, depression, addictions) Mental Challenges (e.g.: memory, focus, learning challenges) What is missing from your life? What would make your life more fulfilling? _ What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well lived a life of few or no regrets? Do you laugh? How often?

YOUR THOUGHTS ARE CRITICAL TO OUR SUCCESS IN HELPING YOU Your nervous system is the master system and controller of your body. Health and wellness are therefore mediated through your nervous system. In our office we have a unique and modern approach to supporting and expanding your health by improving how your nervous system performs. The Core Score is the results of the series of tests with the Insight technology that your doctor had ordered on you, scales from 0-100. The higher the score, the better your Core Score. A graph representing this is below. Lifestyle stress adversely affects your nervous system and general health. Many times, when people think they have a back problem, what they really have is a health problem that is a result of the way they are living. Please answer the following questions so we may better understand how to help you: 1. On a scale of 1 to 10 (10 being the most important) how important is your health to you? On the scale below: 2. Place an X to score where you think you are today 3. Please circle where you would like to be (your goal) 90-100 (EXCELLENT) 80-89 (GOOD) 80-79- (TRANSITION) 60-69 (CHALLENGED) 4. How long do you think it might take to get to where you circled? 5. What things might you need to change to help reach your goal? A. B. C. D. 6. If we could make recommendations that would not only address your main concerns, but could also help with improving your overall health, would you like to hear them? Yes or No

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