DR. SUSAN L. STREIFFPractice of Chiropractic

Date -------PATIENT INFORMATION

Patient Name (Last, First MI) Social Security Number:

Street Address City State Zip Code

Home Phone Work Phone Cell Phone Sex( ) ( ) ( ) o Female 0 Male

Marital Status Student Status Date of Birth

0 Single 0 Married 0 Other 0 Full Time o PartTime o N/A Month_Day_ Year

Employment Status o N/AI Employero Full timeD Part time 0 Retired

Employer Address State Zip Code

Person to Contact In Case of Emergency Emergency Phone How did you hear about us?( )

Any Other Information We Should Know About? (Allergies, Diet Restrictions, Other)

Responsibility StatementYour insurance is a method for you to receive reimbursement for feesyou have paid the physician for services rendered. Havinginsurance is not a substitute for payment. Many companies have fixed allowance or percentages based on your contract with them;.not our office. It is your responsibility to pay the deductible co-insurance and any other balances not paid by your insurance. Wewill assist you in receiving reimbursement as much as possible, but you are resoonsible for your bill and your claims.

RESPONSmLE PARTY - PLEASE COMPLETE IF PERSON IS NOT THE PATIENT

Responsible Party (Last, First, MI) Relationship of Responsible Party to the Patiento Self 0 Spouse 0 ChildO Other

Street Address City & State Zip Code

Home Phone Work Phone Social Security Number Date of Birth

Marital Status Sex Student Statuso Single 0 Married 0 Other o Male 0 Female o Full Time 0 Part Time 0 N/A

Employment Status Employer Nameo FuH timeo Part time 0 Retired 0 N/A

Employer Address State Zip Code

D INSURANCE INFORMATIONHave you provided the office with your insurance card(s) for copying? Office verified'Note primary & secondary (ifapplicable) insurance company name(s): Primary: Secondary:Please pay co-payment (per your insurance agreement) at the time of your visit. Thank you.

Rev. 003 01202011

Body & Mind Wellness CenterSusan L. Streiff, D.C.

135 N. Greenleaf, Suite 110Gurnee, IL 60031-3371

Telephone: (847) 263-8900Fax: (847) 724-1957

AUTHORIZATION/ASSIGNMENT OF MEDICAL BENEFITS

I hereby authorize release of any information regarding my treatment, or diagnosis of mycondition that the doctor considers appropriate, or order to file a claim with my insurancecompany. Irequest such payment be made directly to the practice named on this page forany amounts due for such medical care.

Iunderstand Iam financially responsible for any balance not covered by my insuranceearner,

A copy ofthis signature is as valid as the original.

Patient or Guardian Date

Revision 001 10/27/05

DR SUSAN L. STREIFFPRACTICE OF CHIROPRACTIC

135 N. Greenleaf, Suite 110Gurnee, IL 60031847-263-8900

1920 Waukegan Rd, Ste.7Glenview,IL 60025

847-724-8680

Patient History

Nmne: ~ _ Dme: _

CruefComplamt:, _How long have you had this condition?Have you had this or similar conditions in the past? _How long has this episode been active? _De~ribeyollmjury:, ~ __ ~--~_=----------Is this condition getting progressively worse? Yes_ No Constant Comes & GoesIs this condition interfering with your Work__ Sleep__ Daily routme__ Other _What aggravates the condition? _Does the pain radiate anywhere? _Is the pain intermittent or constant? _Describe YOll work activities: _Describe your recreational activities: _Other physicians seen for this conditions, _Any X-Rays taken? Urinalysis Blood Tests Other. _Are you taking any medications? Yes__ No What kind? _Any non-prescription drugs? _Major illnesses? _M~orI~uries? _Surgical operations? _Last physical examination and physician's name _Secondarycomplaints: _

• We invite you to discuss with us any questions regarding our services. The best health services are based on afriendly. mutual understanding between provider and patient.

• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have beenmade with the business manager. If account is not paid within 90 days of the date of service and no financialarrangements have been made, you will be responsible for any expenses incurred in collecting your account.

• I authorize and request the performance of chiropractic services for myself and give my consent to any advisable andnecessary procedures, laboratory and x-rays to be administered by the attending physician or by hislher supervisedstaff for diagnostic purposes and treatments.

• r understand the above information and guarantee this form was completed correctly to the best of my knowledge andunderstand it is my responsibility to in form this office of any changes in my medical status.

Signature _ Date _

Revision 00 I 10/3 1105

)1EDICAL mSTORY FORMPrintName: _

Check all applicable a Diabetes a Learning disabilitiesQ Diverticular disease a Liver or gallbladder

boxes. disease -tstones)a Drue: addiction a Mental illness

a Arthritis a Eatine: disorder a Mental retardationa EpilepsY Q Mie:raine headaches

a Allergies/hayfever a Emphysema 0 Neurological problems(Parkinson's, paralysis)

a Asthma a Eyes, ears, nose, throat problems a Obesitya Alcoholism a Environmental sensitivities a Osteoporosisa Alzheimer's disease a Fibromyal2ia a Pneumoniaa Autoimmune disease a Food intolerance a Seasonal affective

disordera Blood pressure problems 0 Gastro esonhazeal reflux disease a Sinus problemsa Bronchitis a Genetic disorder a Skin problemsa Cancer a Glaucoma a StrokeQ Chronic fatigue a Gout a Thyroid problems

svndromea Carpal tunnel syndrome a Heart disease a Tuberculosisa Cholesterol, elevated a Infection, chronic a Ulcer0 Circulatory problems 0 Inflammatory bowel disease a Urinary tract infection0 Colitis 0 Irritable bowel syndrome a Varicose veinsQ Depression 0 Kidney or bladder disease Q Other:

Medical histoDecreased sex drivea BPH o SIDInfertili a Other:o Prostrate cancer

Medical history (women only)0 Menstrual Irrezularlries a Endometriosis a Decreased sex drivea PMS a Pelvic inflammatory disease Q SIDQ Date of last menstrual cycle Q # of children: Q Wertility

I I0 Length of cycle days a # of pregnancies; 0 Fibroeystie breastsa Interval of time between a C-section a Breast cancer

cycles:Q Any recent changes in a Date of last gynecological a Menopause

normal menstrual flow (e.g. exam: _'--_I_-heavier, large clots, scanty)

a Ae:eof first period: Q Mammoeram (+) (-) Q Sure:ical menopausea Fibroidslovarian cysts Q PAP smear (+) ( -) Q Other:a Vaginal infections a Oral contraceptive

Famil histo arents and siblin so Arthritis, rheumatoid a Diabetes a Neurol .cal disordersQ Asthma a Dru addiction Q Obesia Alcoholism 0 Glaucoma a Osteo orosisQ Alzheimer's disease a Heart disease o Strokea Cancer a Mental illness a SuicideQ De ression a Migraine headaches Q Other:

Rev 001021106