1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND (701)

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Brian Strickland
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1 AKER CHIROPRACTIC Dr. JaNyne Aker, D.C Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND (701) PATIENT INFORMATION: TODAY S DATE: / / Name First MI Last Address City State Zip Primary Phone ( ) Work Phone ( ) / Cell Phone ( ) / Date of Birth / / Gender: M / F Marital Status: Single/Married/Other SSN - - Employment Status: Employed / FT Student / PT Student /Other / Retired / Self Employed Occupation: Employer: INSURANCE INFORMATION: Primary Insurance: Policy Holder s Date of Birth: / / Secondary Insurance: Policy Holder s Date of Birth: / / IS THIS AN AUTO OR WORK INJURY Y/N IF SO, CLAIM #

3 Patient Name Date / / PHQ: PAGE 2 What type of regular exercise do you perform? O None O Light O Moderate O Strenuous For each of the conditions listed below, place a check in the Past column if you have had the condition in the past. If you presently have a condition listed below, place a check in the Present column. Past Present Past Present Past Present O O Headaches O O High Blood Pressure O O Diabetes O O Neck Pain O O Heart Attack O O Excessive Thirst O O Upper Back Pain O O Chest Pains O O Frequent Urination O O Mid Back Pain O O Stroke O O Smoking/Use Tobacco O O Low Back Pain O O Angina O O Drug/Alcohol Dependence O O Shoulder Pain O O Kidney Stones O O Elbow/Upper Arm Pain O O Kidney Disorders O O Allergies O O Wrist Pain O O Bladder Infection O O Depression O O Hand Pain O O Painful Urination O O Systemic Lupus O O Hip/Upper Leg Pain O O Loss of Bladder Control O O Epilepsy O O Knee/Lower Leg Pain O O Prostate Problems O O Dermatitis/Eczema/Rash O O Ankle/Foot Pain O O Abnormal Weight Gain/Loss O O HIV/AIDS O O Loss of Appetite Females Only O O Jaw Pain O O Abdominal Pain O O Birth Control Pills O O Joint Swelling/Stiffness O O Ulcer O O Hormonal Replacement O O Arthritis O O Hepatitis O O Pregnancy O O Rheumatoid Arthritis O O Liver/Gall Bladder Disorder O O General Fatigue O O Cancer Other Health Problems/Issues O O Muscular Incoordination O O Tumor O O O O Visual Disturbances O O Asthma O O O O Dizziness O O Chronic Sinusitis O O Indicate if an immediate family member has had any of the following: O Rheumatoid Arthritis O Heart Problems O Diabetes O Cancer O Lupus O List all the surgical procedures you have had and times you have been hospitalized: Patient Signature Date / /

4 PATIENT NAME: PHQ: PAGE 3 Do you currently smoke tobacco of any kind? Yes / Former smoker / Never been a smoker If yes, how often do you smoke? Current every day smoker / Current sometimes smoker If yes, what is your level of interest in quitting smoking? No interest Very Interested Current medications, including frequency and dosage if known. If there are no current medications, check here: 1) 5) 2) 6) 3) 7) 4) 8) List any known allergies you have had to any medications. If no allergies are known, check here 1) 3) 2) 4) Briefly list your main health problems: Has any doctor diagnosed you with Hypertension/High Blood Pressure presently? Yes / No If yes, please describe: Has any doctor diagnosed you with Diabetes presently? Yes / No If yes, what kind? Type I / Type II If yes to Diabetes, was your blood lab-work test for hemoglobin A1c > 9.0%? Yes / No / Not Sure If yes, other comments regarding Diabetes: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes / No ****************************************************************************************** To be performed by clinic staff: Height: inches Weight: pounds BP: / AUTHORIZATION Health care professionals who provide a service of neck manipulation are required to explain that there have been rare cases of injuries; stroke and neurological damage. Incidences of these injuries are approximately one (1) per 10 million treatments. Other complications may include soreness, strain, sprain, fracture or disc injury. However, these complications are also rare occurrences. I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor of chiropractic to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the chiropractic group insurance benefits otherwise payable to me. I understand that my chiropractic insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. X Signature of Patient (parent or guardian if a minor) Date

5 AFTER HOURS/EMERGENCY VISITS/NO SHOWS *I understand that if I feel I need to be seen outside of the regular office hours, there will be a $35.00 emergency fee. My insurance may not cover this and I understand that in the event I decide I need to seek treatment, I will be asked to sign a form stating I will pay this fee in the event my insurance does not. *I also understand that if I miss more than 2 appointments in a calendar year, I will be charged $20 for each missed appointment thereafter, as a courtesy both to my provider as well as other patients waiting to get in with my provider. This fee will not be billed to insurance. Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your PHI we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my PHI will be used and I agree to these policies and procedures X Printed Name of Patient X Signature of Patient (parent/guardian if a minor) Date / /

First Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address

First Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address Date of Birth Social Security Number - - First Name MI Last Name Address City State ZIP Phone (H) (W) (Cell) (Please circle the preferred contact number) Email Address Occupation Full Time/Part Time Employer