Welcome to Plains Chiropractic & Acupuncture 3750 32nd Ave S. Suite #103∙ Grand Forks, ND 58201∙ 701.775.1034 Name: ______Date: ______Address: ______Phone: ______Cell: ______Work: ______E-mail: ______Age: ______Birth Date: ______Social Security #: ______Sex: ___ Male ___ Female Marital Status: S M D W Spouse/Guardian: ______# of Children: ______Occupation: ______Employer: ______Work Phone: ( ) ______Whom may we thank for your referral? ______Primary Care Provider: ______Emergency Contact: ______Phone: ______Address: ______Purpose of this appointment: ______Date symptoms appeared or accident occurred: ______What surgeries have you had? ______Have you been treated for any health conditions in the last year? Yes____ No______If yes, please describe: ______What medications, supplements, or drugs are you taking? ______

Areas of Interest (Please mark areas of interest or if you desire more information) ___ Wellness Care ___Children’s Care ___Ear Infection/ Colic/ ADD/ADHD ___Women’s Health ___Acupuncture ___Nutritional Supplements ___Headaches ___Neck/ Lumbar Pillows ___ Orthotics ___Weight Loss Information ___Detoxification Other______

Authorization and Release: I authorize payment of insurance benefits directly to the Plains Chiropractic & Acupuncture. I understand and agree to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations and coordination of care. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. This authorization is to apply to all occasions of service until it is revoked in writing. Patient or Authorized Person’s Signature: ______Date: ______The following questions are necessary so that we may properly file your insurance for you. Please answer as fully as possible.

1. Type of insurance: Medicare____ Medicaid____ Group Health Plan______Other______2. Insured’s Name (as it appears on the insurance card):______3. Insured’s Address (if same as patient put “same”)______4. Patient Status (please circle): Single Married Other Employed Full-time Student Part-time Student 5. Other Insured’s Name (if applicable):______Other Insured’s Policy or Group Number: ______Employer’s Name or School Name: ______Insurance Plan Name or Program Name: ______6. Is the condition we are treating related to current or previous employment? Yes______No______7. Is the condition we are treating related to an auto accident? Yes_____ No______8. Is the condition we are treating related to another type of accident? Yes______No______9. Insured’s Policy Group or FECA Number: ______Employer Name or School Name: ______Insurance Plan Name or Program Name: ______10. Is there another health benefit plan? Yes______No______If yes, please list: ______

Medicare Only All doctors have been instructed to ask the following question of all Medicare patients. 1. Do you or your spouse work for a company that provides you with health insurance? Yes__ No__ 2. Are you entitled to Medicare because of End Stage Renal Disease? Yes_____ No______3. Is the illness or injury the result of an accident or illness that occurred at work? Yes____ No_____ 4. Is this illness or injury the result of an accident or other injury? Yes______No______5. Has the treatment for this accident or illness been authorized by the Veteran’s Administration Yes___ No___ 6. Are you entitled to any benefits under the Federal Black Lung Program? Yes_____ No_____ 7. Do you have a Medicare Medigap Policy? Yes_____ No_____ Name of Company______8. Do you have a Medicare Supplement Policy? (Policy provided by employer you retired from): Yes____ No_____

Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: a basis for planning my care and treatment, a means of communication among the many health professionals who contribute to my care, a source of information for applying my diagnosis information to my bill, a means by which a third-party payer can verify that services billed were actually provided, and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

I request the following restrictions to the use or disclosure of my health information:

____Accepted ______Denied Signature of Patient or Authorized Representative______Date: ______

Using the symbols indicated below; please mark the areas on the illustrations where you are experiencing pain. A: Dull, Nagging Ache N: Numbness, tingling B: Burning S: Sharp, Stabbing

1. What are your major symptoms?______2. Have you ever had the same or a similar condition? Yes ___No___ If Yes, when ______How did it originally occur? ______Has it become worse recently? Yes____ No____ Same____ Better____ Gradually Worse_____ If yes, when and how? ______3. How frequent is the condition? Constant ______Daily ______Intermittent ______Night Only______4. How long does it last? All Day______Hours______Minutes______5. Are there any other conditions or symptoms that may be related to your major symptom? Yes___ No_____ If yes, please describe______6. Is there anything you can do to relieve the problem? Yes____ No____ If yes, please describe______If no, what have you tried to do that has not helped? ______7. What makes the problem worse? Standing____ Sitting____ Lying____ Bending____ Lifting ___Twisting _____Other______8. Have you had any broken bones? Yes____ No____ If yes, please list and give dates ______9. List any major accidents you have had other than those that might be mentioned above: ______10. To your knowledge, have you had any diseases, major illnesses, or injuries not indicated on this form either in the past or the present? Yes____ No____ If yes, please explain______11. Women Only: Are you pregnant or is there any possibility you may be pregnant? Yes___ No____

No Symptoms Extreme Symptoms I______I Please place an “X” on the line above to indicate the severity of your problem

Please Check All That Cancer Mental Illness Apply: Diabetes Multiple Sclerosis Your Past/Present Family Medical History Heart Disease Seizures Medical Allergies High Blood Pressure Stroke Conditions Arteriosclerosis Kidney Disease Parents Health: AIDS/HIV Asthma Liver Disease Good Fair Poor Alcoholism Alcoholism Allergies Anemia Excellent  Good  Fair Heavy sleep Concussion/head injury Appendicitis Poor Dream-disturbed sleep Arteriosclerosis Sleep Position: Waking up tired/sluggish Respiratory Asthma Side  Back  Stomach Night Sweats Chest congestion Bleeding Disorders Chest tightness Blood Sugar Disorders Difficulty breathing Cancer Typical Daily Menu Morning______Shortness of breath Chronic Fatigue/ CFS Snack______Head, Eyes, Ear, Nose, Throat Persistent Cough Crohn’s/IBS Noon______Heaviness in the head Coughing up blood Diabetes _ Confusion Phlegm/mucus Emphysema Snack______Difficulty concentrating Color______Epilepsy Evening______Headache _ Fibromyalgia Blurred vision Goiter Snack______Spots in eyes Gout Dry eyes Heart Disease Red eyes Hepatitis Your lifestyle Itchy eyes Alcohol: Yes / No Herpes Ringing in the ears # Of drinks per week______Cardiovascular High Blood Pressure Ear aches Heart failure High Cholesterol Tobacco: Yes / No How Often? ______Ear infections Chest Pain Kidney Disease Recreational drug use: Yes / No Sinus problems Palpitations Liver Disease Stress Level: Nose bleeds Irregular heart rate Low Blood Pressure Low Moderate High Dry mouth/throat Murmurs Multiple Sclerosis Do you enjoy your work? Yes / Scratchy/Itchy throat Hypertension Pacemaker No Recurrent Sore throat Hypotension Pleurisy Difficulty swallowing Swelling of the ankles Pneumonia Emotions commonly felt: TMJ problems Varicose veins Polio Anger Grinding teeth Blood clots Rheumatic Fever Irritability Rheumatic fever Seizures Happiness Skin, Hair, Nails Stroke Sadness Dry skin Gastrointestinal STD’s Anxiety Thyroid Disorders Fear Itchy skin Nausea/Vomiting Tuberculosis Depression Eczema Belching Tumors Worry Psoriasis Gas Whooping Cough Mood Swings Rashes Indigestion/Bloating Major Nervousness Hives Heartburn Trauma______Mental Tension Hair loss Ulcers ______Dry, brittle nails Abdominal pain; Other______Interests and Hobbies: Soft nails Acute, severe pain: ______Y / N _ Diarrhea ______Musculoskeletal Constipation Do you have any _ Neck/Shoulder tightness Laxative use infectious diseases? ______Neck pain Hemorrhoids Yes / No If yes, please _ Upper back pain describe: ______Rectal bleeding Lower back pain ______Bloody stool Rib pain ______Black stool Muscle pain Past Surgeries/ Physical Exercise: Painful joints Hospitalizations/Major Type______Radiating pain Genito-Urinary Tract Frequency______Illnesses: Limited use Painful urination ______Impaired urination Type______Other ______Frequent urination ______Frequency______Unable to hold urine ___ _ Neurological Blood in urine Numbness Frequent UTI’s General Symptoms Tingling Your Diet Kidney stones Fatigue Fainting Glasses of Water consumed per Increased libido Lack of strength Seizures day: ______ Decreased libido Frequent colds/flu Paralysis Coffee: Yes / No  Infertility # of cups per day? ______Slow wound healing Muscle weakness Soft Drinks: Yes / No Chronic infections Loss of coordination # of 12oz drinks per day? __ Lymph node swelling Loss of balance Male Reproductive Feeling hot Dizziness/Lightheadedness Impotence Your Sleep Feeling cold Involuntary movements Premature ejaculation Average # of hours per Chills and Fever Poor concentration Nocturnal emission night?___ Cold hands/feet Mental confusion Testicular pain Quality of Sleep: Recent weight loss/gain Memory problems Prostate problems Poor sleep Speech problems Gynecological Pale Dark Red Date last period began If yes, what Age at first menses______PMS ______age______Length of cycle______Irregular periods _ Breast lumps Duration of menses days # Of Painful periods Amount of flow: pregnancies______Other Concerns: Clots Heavy Moderate # Of live ______Light Vaginal discharge births______Color of blood: Color______Menopause _ __ 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. The doctor will not be held responsible for any pre-existing medically diagnosed conditions or for any errors or omissions that I may have made in the completion of this form.

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: soreness, soft tissue injury, fractures, disc injuries, dislocations, muscle strain, physical therapy burns, 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. The most recent studies estimate that the incidence of stroke is 1 in every 5 million upper cervical adjustments. 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 have myself 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 Clinic Name of Doctor Treating this Patient Plains Chiropractic & Acupuncture P.C. 3750 32nd Ave S Suite #103 Grand Forks, ND 58201

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

Printed Name of Patient: ______

Signature of Patient: ______Date: ______

Signature of Patient’s Representative: ______Date: ______

Translated by: ______Date: ______