CHIROPRACTIC REGISTRATION AND HEALTH HISTORY FORM

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CHIROPRACTIC REGISTRATION AND HEALTH HISTORY FORM PATIENT INFORMATION Patient Name: Date: Social security #: Address: E-mail:_ Birthdate: ( ) Married ( ) Single ( ) Divorced ( ) Widowed ( ) Minor ( ) Partnered for years Employer/school Employer address Employer phone # Spouse s name: Spouse s employer: Whom may we thank for referring you? INSURANCE INFORMATION Who is responsible for this account? SS# of insured Birthdate of insured Relationship to patient Insurance Co. Group # Policy # Assignment and release: I certify that I, and/or my dependents, have insurance coverage with _ and assign directly CIMW all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use for my signature on all insurance submissions. The above named doctor may use my health care information and may disclose such information to the above named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed. X Date: PHONE NUMBERS Cell Home Best time to reach you Emergency Contact: Name: Number: ACCIDENT INFORMATION Is this condition due to an accident? ( ) Yes ( ) No If yes, please complete personal injury form PATIENT CONDITION Reason for visit When did your symptoms appear? Is your condition getting worse over time? Have you seen other doctors for this complaint? Name: Please rate the severity of your pain from 1-10 (10 is the pain) Is it constant or does it come and go? How often do you have this pain?_ Does it interfere with your: ( ) work ( ) sleep ( ) daily routines ( ) recreation Activities which are painful: ( ) standing ( ) sitting ( ) lying down ( ) walking ( ) bending HEALTH HISTORY Date of last: Physical Exam Spinal Exam Spinal X-ray Blood/Urine test_ MRI/CT/bone scan

Mark with an X to indicate if you have/had any of the following. Please also mark any that apply to immediate family, and indicate the relationship to you. AIDS/HIV ( ) Hepatitis ( ) Alcoholism ( ) Hernia ( ) Allergy Shots ( ) Herniated Disc ( ) Anemia ( ) High Cholesterol ( ) Anorexia ( ) Kidney disease ( ) Appendicitis ( ) Liver disease ( ) Arthritis ( ) Migraines ( ) Asthma ( ) Miscarriage ( ) Bleeding disorders ( ) Multiple Sclerosis ( ) Breast Lump ( ) Osteoporosis ( ) Bronchitis ( ) Pacemaker ( ) Bulimia ( ) Parkinsons ( ) Cancer ( ) Polio ( ) Cataracts ( ) Prostate problems ( ) Chemical dependency ( ) Prosthesis ( ) Diabetes ( ) Psychiatric Care ( ) Emphysema ( ) Stroke ( ) Epilepsy ( ) STD ( ) Fractures ( ) Suicide attempts ( ) Goiter ( ) Thyroid problem ( ) Gout ( ) Tonsillitis ( ) Heart Disease ( ) TB ( ) Tumors ( ) Ulcers ( ) Exercise: ( ) none ( ) mild ( ) moderate ( ) heavy Work Habits: ( ) sitting ( ) standing ( ) light labor ( ) heavy labor Other ( ) Other Habits: ( ) smoking quantity ( ) drinking quantity ( ) coffee/caffeine quantity ( ) stress reason_ Pregnancy history: # of pregnancies # of live births # of miscarriages vaginal/c-section? are you pregnant now? If yes, due date? Injuries/Surgeries- Please describe major injuries and any surgical procedures performed: MEDICATIONS ALLERGIES SUPPLEMENTS Please list medications, what they are for, and how long you have been taking them: 1-2- 3-4- Please list supplements you are currently taking, where you purchased them, and the dose (if known): 1-2- 3-4-

PATIENT GOALS/EXPECTATIONS Please tell us what your goals/expectations of your care are- ( ) relief care- primary goal is to relieve your symptoms ( ) corrective care- complete the correction begun in the relief care ( ) stabilization- stabilize structures supporting the spine to prevent future episodes ( ) wellness- promotion of optimal functioning of all bodily systems ( ) other:

QUADRUPLE VISUAL ANALOGUE SCALE INSTRUCTIONS: Please circle the number that best describes the question being asked. NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your average pain levels and pain at minimum / maximum using the last 3 months as your reference. If you have completed this form before, indicate you average pain level since the last time you completed this form. 1. What is your pain RIGHT NOW? no pain _ possible pain 2. What is your TYPICAL or AVERAGE pain? no pain _ possible pain 3. What is your pain level AT ITS BEST (How close to 0 does your pain get at its best)? no pain _ possible pain What percentage of your awake hours is your pain at its best? % 4. What is your pain level AT ITS WORST (How close to 10 does your pain get at its )? no pain _ possible pain What percentage of your awake hours is your pain at its? % A= Ache B= Burning D= Dullness N= Numbness P= Pins & Needles R= Radiation S= Stabbing NAME DATE

BACK BOURNEMOUTH QUESTIONNAIRE Patient Name Date _ Instructions: The following scales have been designed to find out about your back pain and how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel. 1. Over the past week, on average, how would you rate your back pain? No pain Worst pain possible 2. Over the past week, how much has your back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)? 3. Over the past week, how much has your back pain interfered with your ability to take part in recreational, social, and family activities? 4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling? Not at all anxious Extremely anxious 5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? Not at all depressed Extremely depressed 6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your back pain? Have made it no worse Have made it much worse 7. Over the past week, how much have you been able to control (reduce/help) your back pain on your own? Completely control it No control whatsoever Examiner OTHER COMMENTS: With Permission from: Bolton JE, Breen AC: The Bournemouth Questionnaire: A Short -form Comprehensive Outcome Measure. I. Psychometric Properties in Back Pain Patients. JMPT 1999; 22 (9): 503-510.

NECK BOURNEMOUTH QUESTIONNAIRE Patient Name Date _ Instructions: The following scales have been designed to find out about your neck pain and how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel. 1. Over the past week, on average, how would you rate your neck pain? No pain Worst pain possible 2. Over the past week, how much has your neck pain interfered with your daily activities (housework, washing, dressing, lifting, reading, driving)? 3. Over the past week, how much has your neck pain interfered with your ability to take part in recreational, social, and family activities? 4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling? Not at all anxious Extremely anxious 5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? Not at all depressed Extremely depressed 6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your neck pain? Have made it no worse Have made it much worse 7. Over the past week, how much have you been able to control (reduce/help) your neck pain on your own? Completely control it No control whatsoever Examiner OTHER COMMENTS: With Permission from: Bolton JE, Humphreys BK: The Bournemouth Questionnaire: A Short-form Comprehensive Outcome Measure. II. Psychometric Properties in Neck Pain Patients. JMPT 2002; 25 (3): 141-148.

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