YOUR VITAL INFORMATION WELL…come to your first step toward optimal health and healing!

Please tell me your biggest health concern:

Please tell me your most important health goal:

Please complete all questions using black ink. Full Name: Today’s Date:

Address: City/State/Zip:

PLEASE CIRCLE THE BEST NUMBER TO REACH YOU:

Home Phone: Work Phone: Cell Phone:

O.K. to call? Y or N O.K. to leave message? Y or N O.K. to call? Y or N O.K. to leave message? Y or N O.K. to call? Y or N O.K. to leave message? Y or N

Is it O.K. for us to text you? Y or N

Birthdate: Age: Social Security #:

Marital Status: M W D S Your E-Mail address:

O.K. to e-mail? Y or N

Your Employer: Occupation:

Spouse’s/Significant Other’s Name: Spouse’s/Significant Other’s Employer:

Children’s Names & Ages: Is your family supportive of your pursuit of health and wellness?

Your Favorite Hobbies: Are you currently able to enjoy hobbies without pain or stress?

Most patients are referred to our office by a caring family member or friend…

Who may we thank for referring you? Other?

Research shows that your spine should be checked regularly. How many times have you visited a chiropractor in your lifetime? � Never

Last visit? Dr.

Are you here because of a recent auto or work injury? Date of Accident:

Who was the last doctor who put you on a total health development program?

Drugs can cause various side effects, hide the severity of health conditions and/or hinder the body’s ability to heal.

What drugs do you currently take? Vitamins / Supplements?

Stress can cause or accelerate spinal damage. Rate your stress level over the past 90 days? (1-10 scale with 10 = high)

Surgeries you’ve had: Ever diagnosed with cancer? Type?

Poor posture leads to poor health and often indicates a spinal condition. How would you rate your posture? (1-10 scale with 10 = Excellent)

Family History of: heart disease cancer stroke back problems other _______________________________ (please circle)

What are your health objectives / goals for care after your current symptoms go away and you are feeling better?

Are you healthier than you were 5 years ago? If so, how did you achieve that?

If not, what is your plan to help you prevent illness and disease, as well as create “health” for your future?

If the doctor feels that chiropractic can help you, are you willing to follow-through with her best recommendations?

Emergency Contact: Phone Number: Relationship:

(Please turn over) è

The vast majority of our patients have experienced literally hundreds of impacts that could cause subluxations (spinal misalignments). Help us discover a few of yours.

1. How many total auto accidents have you been in? _____________ Motorcycle accidents? Yes No

Briefly describe type of accident(s) (i.e. rear-ended, head on collision, etc.), speed of impact, any care received & date(s): ___________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ 2. Which of the following sports have you been involved in? (please circle) football, basketball, soccer, field hockey, gymnastics, horsebackriding, martial arts, roller blading, other: _____________________________________________________________________________________________________

3. Have you ever…(please check) ( ) fallen down the stairs ( ) slipped on ice or snow ( ) broken a bone ________________________________ explain & give date(s)

( ) had a stress or strain while working ( ) had a sports injury ( ) been hospitalized ________________________________________________________

explain & give date(s)

4. Repetitive activities can cause subluxation…for example, do you … (please check)( ) sit more than four hours per day ( ) spend a lot of time on the telephone ( ) spend a lot of time at the computer ( ) drive more than two hours per day

5. Are you a …(please check) ( ) computer operator ( ) assembly line worker ( ) construction worker ( ) truck driver ( ) single or working mother ( ) ___________________________

Body Signal How long have you had the below

complaints?

How often do you have the below

complaints?

Describe (dull, sharp, achy, burning,

throbbing, numbness)

Worse in AM, PM, anytime?

After activity?

Low Back Pain

Fatigue

Carpal Tunnel Syndrome

Neck Pain

Leg/Foot Problems

Ear Infections

Headaches

Asthma

Frequent Colds/Infections

Upper/Mid Back Pain

Allergies

Extremity Pain/Joint Pain

Shoulder Pain

Sinus Problems

Digestive Problems

Menstrual Problems

Other? _____________________ i.e. High Blood Pressure, etc.

________________________________________________________________________________ ____________________________________________ Patient’s Signature Date

________________________________________________________________________________ ____________________________________________ Guardian’s Signature Authorizing Care for Minor Date

� I acknowledge and agree that I have received a copy of the Notice of Rights for access to health records and privacy practices for review and to keep for my recordson the date identified below. � I authorize Concierge Chiropractic, P.C. to release any information needed to help me receive insurance reimbursement.

________________________________________________________________________________ ___________________________________________Signature Date

Subluxations (spinal misalignments) can cause dysfunction in the entire body. They can also put pressure on nerves for months or even years before you feel the effects. Please check the health complaints or body signals you are currently experiencing and describe each. What is your primary complaint today? ____________________________________________________________________

Name_____________________________________________ Date _________________________

HEALTH HISTORY OF FAMILY MEMBERSThe reason for this form is to assist the doctor by providing past health history information for her review.

Condition Self Father Mother Spouse Brothers Sisters Children

Arthritis

Asthma

Back Trouble

Cancer

Constipation

Diabetes

Disc Problems

Drinker

DrugAddictionEmphysema

Epilepsy

Headaches

HeartTroublesHigh BloodPressureKidneyTroubleMigraine

Nervousness

Neuritis

Neuralgia

PinchedNerveScoliosis

Sinus Trouble

Smoker

SportsActivitiesStomachTrouble

ACCESS TO HEALTH RECORDS NOTICE OF RIGHTS

This notice explains the rights you have to access your health record, and when certain information in your health record can be released without your consent. This notice does not change any protections you have under the law.

YOUR RIGHT TO ACCESS AND PROTECT YOUR HEALTH RECORD You have the following rights relating to your health record under law:

• A health care provider, or a person who gets health records from a provider, must haveyour signed and dated consent to release your health record, except for specific reasonsin the law.

• You can see your health record for information about any diagnosis, treatment, andprognosis.

• You can ask, in writing, for a copy or summary of your health record, which must be givento you promptly.

• You must be given a copy or a summary of your health record unless it would bedetrimental to your physical or mental health, or cause you to harm another.

• You cannot be charged if you request a copy of your health record to review your currentcare.

• If you request a copy of your health record and it does not include your current care, youcan only be charged the maximum amount set by Oklahoma law for copying your record.

RELEASE OF YOUR HEALTH RECORD WITHOUT YOUR CONSENT There are specific times that the law allows some health record information held by your provider to be released without your written consent. Some, but not all, of the reasons for release under federal law:

• For specific public health activities• When health information about

victims of abuse, neglect, ordomestic violence must be releasedto a government authority

• For health oversight activities• For judicial and administrative

proceedings• For specific law enforcement

purposes• For certain organ donation purposes

• When health information aboutdecedents is required for specificindividuals to carry out their dutiesunder the law

• For research purposes approved bya privacy board

• To stop a serious threat to health orsafety

• For specialized governmentfunctions related to national security

• For workers’ compensation purposes

Health information may be released without your consent in a medical emergency, or when a court order or subpoena requires it. The following include some of the agencies, persons, or organizations that specific health record information may or must be released to for specific purposes, or after certain conditions are met:

• The Departments of Health, HumanServices, Public Safety, Commerce,Employee Relations, Labor &Industry, and Education

• Insurers and employers in workers’compensation cases

• Ombudsman for Mental Health andMental Retardation

• Health professional licensingboards/agencies

• Victims of serious threats of physicalviolence

• The State Fire Marshal• Local welfare agencies

• Medical examiners or coroners• Schools, childcare facilities, and

Community Action Agencies totransfer immunization records

• Medical or scientific researchers• Parent/legal guardian who did not

consent for a minor’s treatment,when failure to release healthinformation could cause serioushealth problems

• Law enforcement agencies• Insurance companies and other

payers paying for an independentmedical examination

Terms of Acceptance

When a patient seeks chiropractic health care and we accept a patient forsuch care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal: to eliminate misalignments within the spinalcolumn which interfere with the expression of the body’s innate wisdom. It isimportant that each patient understand both the objective and the methodthat will be used to attain our goal. This will prevent any confusion ordisappointment.

Adjustment: the specific application of forces to facilitate the body’s correctionof vertebral subluxation. Our chiropractic method of correction is specificadjustments of the spine.

Health: a state of optimal physical, mental, and social well-being, not merely theabsence of disease of infirmity; 100% function; full expression of life.

Vertebral Subluxation: a misalignment of one or more of the 24 vertebrae in thespinal column which causes alteration of nerve function and interference to thetransmission of mental impulses, resulting in a lessening of the body’s innateability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other thanvertebral subluxation, however, if during the course of chiropractic spinalexamination we encounter non-chiropractic or unusual findings, we will adviseyou. If you desire advice, diagnosis, or treatment for those findings, we willrecommend that you seek the services of a health care provider who specializesin that area. Regardless of what the disease is called, we do not offer to treat it.Nor do we offer advice regarding treatment prescribed by others. Our ONLYpractice objective is to eliminate major interference to the expression of thebody’s innate wisdom. Our ONLY method is specific adjusting to correctvertebral subluxations.

I, ___________________________ have read and fully understand the abovestatements.

(Print Name)

All questions regarding the doctor’s objectives pertaining to my care in this officehave been answered to my complete satisfaction. I, therefore, acceptchiropractic care on this basis.

___________________________________________ __________________________Signature Date