PatientInformation:

Name: Today’sDate: / / DateofBirth: / / Age:

StreetAddress: City: State: Zip:

H.Phone:( ) W.Phone:( ) C.Phone:( )

EmailAddress: Howdidyouhearaboutus:

Sex: M FMaritalStatus: Single Married Divorced Separated Widowed Partnership

NameofSignificantOther:

Employment:

Occupation: Isyouroccupationthecauseofyourpain: Yes No

EmergencyContactName(Notlivinginyourhome):

Name: Relationship: Phone:( )

Insured’sName: Insured’sEmployer: RelationshiptoInsured: Insured’sDateofBirth: InsurancePolicy/ID#: InsuranceGroup#: PlanA PlanBAreyouawareifyouhavemetyourdeductiblefortheYear? Yes No

IherebyauthorizeassignmentofmyinsurancerightsandbenefitsdirectlytotheprovidersattheUltimateWellnessCenter(CommonSenseWellnessandAdvancedCareChiropractic,P.A.)forservicesrendered.IfullyunderstandthatIamsolelyresponsibleforanybalancenotpaidbymyinsurancecompanyandagreetopaysupplementco-paymentsifinsurancedoesnotcoverthecostoftheservicesrendered.PatientSignature: Today’sDate:

IagreetoallowtheUltimateWellnessCenter(CommonSenseWellnessandAdvancedCareChiropractic,P.A.)toperformapayrolldeductionifservicesrenderedarenotcoveredbytheinsurancecompany.PatientSignature: Today’sDate:

GeneralInformation:

PreferredOneInformationOnly:

AdvancedCareChiropractic

Pleasemarkyourcomplaints,usingthefollowingletters,accordingtothewhereyouarefeelingthemthendescribethembelow:

A:acheB:burningpainC:crampingD:dullpainR:throbbingpainN:numbnessT:tingling

Doyouhavepainand/ordifficultyperforminganyofthefollowingactivities:(CheckallthatApply) Personalcare Lifting Reading Concentrating Work Driving Sleeping Recreation Walking Sitting Standing SocialLife

PrimaryComplaint(TheMostSevere):

LocationofComplaint: _______________ CauseofComplaint(IfKnown):

Whendidyourcomplaintbegin: Howoftendoesthecomplaintoccur: daily weekly Other:

Oncethecomplaintbegins,howlongdoesitlast: Constant Weeks Days Minutes Other:

Describethepain: dull aching sharp shooting burning throbbing Other: ___________

Howsevereisthepain(CircleOnoraRange): (Nopain)012345678910(Worsepainimaginable)

Sincethecomplaintbegan,isitgetting: Better Worse UnknownIsthepainworseinthe: AM PM

Whatmakesthecomplaintworse: Whatmakesthecomplaintbetter:

Othercomplaintsorpainsthatoccurwiththecomplaint:

Complaint#2(IfAny):

LocationofComplaint: _______________ CauseofComplaint(IfKnown):

Whendidyourcomplaintbegin: Howoftendoesthecomplaintoccur: daily weekly Other:

Oncethecomplaintbegins,howlongdoesitlast: Constant Weeks Days Minutes Other:

Describethepain: dull aching sharp shooting burning throbbing Other: ___________

Howsevereisthepain(CircleOnoraRange): (Nopain)012345678910(Worsepainimaginable)

Sincethecomplaintbegan,isitgetting: Better Worse UnknownIsthepainworseinthe: AM PM

Whatmakesthecomplaintworse: Whatmakesthecomplaintbetter:

Othercomplaintsorpainsthatoccurwiththecomplaint:

ReasonforyourVisit:

Complaint#3(IfAny):

LocationofComplaint: _______________ CauseofComplaint(IfKnown): ___

Whendidyourcomplaintbegin: Howoftendoesthecomplaintoccur: daily weekly Other:

Oncethecomplaintbegins,howlongdoesitlast: Constant Weeks Days Minutes Other:

Describethepain: dull aching sharp shooting burning throbbing Other: ___________

Howsevereisthepain(CircleOnoraRange): (Nopain)012345678910(Worsepainimaginable)

Sincethecomplaintbegan,isitgetting: Better Worse UnknownIsthepainworseinthe: AM PM

Whatmakesthecomplaintworse: Whatmakesthecomplaintbetter:

Othercomplaintsorpainsthatoccurwiththecomplaint:

Complaint#4(IfAny):

LocationofComplaint: _______________ CauseofComplaint(IfKnown):

Whendidyourcomplaintbegin: Howoftendoesthecomplaintoccur: daily weekly Other:

Oncethecomplaintbegins,howlongdoesitlast: Constant Weeks Days Minutes Other:

Describethepain: dull aching sharp shooting burning throbbing Other: ___________

Howsevereisthepain(CircleOnoraRange): (Nopain)012345678910(Worsepainimaginable)

Sincethecomplaintbegan,isitgetting: Better Worse UnknownIsthepainworseinthe: AM PM

Whatmakesthecomplaintworse: Whatmakesthecomplaintbetter:

Othercomplaintsorpainsthatoccurwiththecomplaint:

Doyouhaveanyofthefollowing(CheckAllThatApply):

Dizziness BlurredVision DifficultySpeaking DifficultySwallowing Bowel/BladderChangesRinginginEars HearingLoss Changesinappetite NightSweats UnexplainedWeightLossNumbness Tingling Fatigue Fever Other:

PleaseDescribeanyfromabove:

Haveyouusedanyself-treatmentfortheComplaint/Complaints: Yes No

Ifyes,what:

HaveyouseenanyotherChiropractic/MedicalDoctorsorotherHealthCareProfessionalsforthecomplaint/complaints:

Yes No Ifyes,whatwastheDiagnosisandTreatment:

____________

WhatareyourHealthGoals:

_________

CurrentHealthHistory:

Doyoucurrentlyhaveanymedicalconditions,pleaselistthediagnosesbelow(Diabetes,Cancer,etc.):

Diagnosis DateDiagnosed

Past Present

Past Present

Past Present

Past Present

Past Present

Past Present

Medications/OverthecounterDrugs:

Medication ReasonforTaking Dosage/FrequencyForhowlong?

Supplements:

Supplement ReasonforTakingDosage/FrequencyForhowlong?

FoodandDrugAllergiesthatyouhaveorhavehad:

PregnanciesandOutcomes(FemalesOnly):

DateOutcomes(FullTerm/Terminated/Miscarriage)Sex(MaleorFemale)Age

/ /

/ /

/ /

/ /

Isthereanypossibilitythatyouarecurrentlypregnant: Yes NoIfyes,howfaralongareyou:

Activities/Hobbies:

SportsorActivitiesyouareactivein:

DoyouExerciseRegularly: Yes NoIfyes,describewhatformandhowoften:

Nutrition:

Whatisyourdailydietlike(e.g.organic,fastfood,homecookedmeals,gasstationfood):

Howmanymealsadaydoyoueat: AreyouCurrentlyonaDiet(Atkins,Vegan,Vegetarian): Yes No

Ifyes,describe:

Habits:

Doyoudrink/usecaffeinatedproducts: Yes NoIfyes,whatandhowmuch:

Doyoudrinkalcoholicbeverages: Yes NoIfyes,whatandhowmuch:

Doyouusetobacco: Yes NoIfyes,howoftenandmuch:

Doyouuserecreationaldrugs: Yes NoIfyes,whatandhowoften:

Haveyoubeendiagnosedwithanyofthefollowinginyourpastorpresenthistory:

AIDS/HIV Yes No Glaucoma Yes No Parkinson’sDisease Yes No

Alcoholism Yes No Goiter Yes No PinchedNerve Yes No

Allergies: Yes No HeartAttack Yes No Pneumonia Yes No

Anemia Yes No HeartDisease Yes No Polio Yes No

Appendicitis Yes No Hepatitis Yes No ProstrateProblem Yes No

Arthritis Yes No Hernia Yes No PsychiatricCare Yes No

Asthma Yes No HerniatedDisk Yes No RheumatoidArthritis Yes No

BleedingDisorders Yes No Herpes Yes No RheumaticFever Yes No

BreastLump Yes No HighBloodPressure Yes No ScarletFever Yes No

Bronchitis Yes No HighCholesterol Yes No Stroke Yes No

Cancer Yes No KidneyDisease Yes No SuicideAttempt Yes No

Cataracts Yes No LiverDisease Yes No ThyroidProblems Yes No

ChemicalDependency Yes No Measles Yes No Tonsillitis Yes No

ChickenPocks Yes No MigraineHeadache Yes No Tuberculosis Yes No

Depression Yes No Miscarriage Yes No Tumors/Growths Yes No

Diabetes Yes No Mononucleosis Yes No TyphoidFever Yes No

EatingDisorders Yes No MultipleSclerosis Yes No Ulcers Yes No

Emphysema Yes No Mumps Yes No VaginalInfections Yes No

Epilepsy Yes No MuscularDystrophy Yes No VenerealDisease Yes No

Fractures Yes No Obesity Yes No WhoopingCough Yes No

Gonorrhea Yes No Osteoporosis Yes No Other:

Gout Yes No Pacemaker Yes No

Previousillnesses,injuries,hospitalizationsorSurgeriesnotlistedabovethatyouhavehad:

Date Description

/ /

/ /

/ /

PastHealthHistory:

Hasanyoneinyourfamilybeendiagnosedwiththefollowing:

Anemia Yes No Gout Yes No MultipleSclerosis Yes No ThyroidProblems Yes No

Arthritis Yes No Hepatitis Yes No Osteoporosis Yes No Tuberculosis Yes No

BleedingDisorders Yes No HeartDisease Yes No Parkinson’sDisease Yes No Tumors/Growths Yes No

Cancer Yes No HighCholesterol Yes No ProstrateProblem Yes No Ulcers Yes No

Diabetes Yes No KidneyDisease Yes No PsychiatricCare Yes No Other:

Epilepsy Yes No LiverDisease Yes No RheumaticFever Yes No

Glaucoma Yes No MigraineHeadache Yes No RheumatoidArthritis Yes No

Goiter Yes No Miscarriage Yes No Stroke Yes No

Areanyofthefollowingaconcernforyou:

PrematureAging Yes No HormoneBalance Yes No CancerPrevention Yes No EyeHealth Yes No ElectomagneticPollution Yes No GlucoseLevels Yes NoEnergyLevels Yes No Cholesterol Yes No Smoking Yes No Memory Yes No Anti-Aging Yes No Other:______________________________

PleaseReadandSignBelow:Ihavereadtheaboveinformationandcertifyittobetrueandcorrecttothebestofmyknowledge,andherebyauthorizeAdvancedCareChiropractic,P.A.andCommonSenseWellnesstoprovidemewithtreatmentinaccordancewiththisstate'sstatutes.

PatientorGuardianSignature: Date:

Directions:Answerthefollowingquestionsbymarkingthenumberedboxthatcorrespondstoyourexperience.A.Heart&Circulation 0123___ B.Lungs,NoseandMouth0123____

Fingers&toescold Asthma Sharpdiagonalcreaseinearlobe Bronchitis Arms&legsoftengotosleep Wheezing/chestsoundswhenbreathing Tinglingsensationsinlegsorfingers Frequentshortnessofbreath Snoringonregularbasis Chroniccough Irregularorskippedheartbeats Coughupphlegmormucous Rapidpoundingpulseatrest Burninginlungs Chestpainextendingtoleftarmorneck Tuberculosis Shortofbreathonexertion Can’ttakefulldeepbreaths Anklesswellfrequently SinusProblems

HayFever Totals(OfficeOnly) Drycrackingorbleedinginsidenose

Sensitivetosmoke/perfume/chemicals Reducedsenseofsmellortaste Totals(OfficeOnly)

0=occurs Never/Rarely 1 = occurs monthly 2 = occurs weekly 3 = occurs daily

FamilyHistory:

OtherHealthConcerns:

HealthyLivingSurvey:

0=occurs Never/Rarely 1 = occurs monthly 2 = occurs weekly 3 = occurs daily C.Stomach,intestines,LiverandGallbladder0123___ D.Bones,JointsandMuscles0123____

Indigestionsaftereating Asthma Burningstomach,relievedbyeating Bronchitis Bloatedfeelingaftereating Wheezing/chestsoundswhenbreathing Diarrhea Frequentshortnessofbreath Constipation Chroniccough Heartburn Coughupphlegmormucous Nauseaaftereating Burninginlungs Coatedtongue Tuberculosis Painfulbetweenshoulderblades Can’ttakefulldeepbreaths Gas/bloating,withanyfood SinusProblems Stoolsarelightincolor HayFever Usealaxative Drycrackingorbleedinginsidenose

Redbloodinstools Sensitivetosmoke/perfume/chemicals Reducedsenseofsmellortaste

Weakmuscles,weakgrip Totals(OfficeOnly) Achesorpainsinjoints Stiffnessorlimitedjointmovement Tightorsorefeelinginmuscles JointsGrateorPoponNormalMovement

MuscleCramps(“CharlieHorses”) VisibleSwellinginJoints Painsdeepinbones Totals(OfficeOnly)

E.AdrenalHyper-Activity0123_ F.ImmuneSystemHyperactivity0123_Rapidpulseatrest(morethan90beatsperminute) BreatheThroughMouth EdemaorFluidRetention PostNasalDrip (Females)Excessivehaironface,arms,legs ChronicLungCongestion (Males)Baldness,excessivehaironarms,back, FoodSensitivityorAllergy muscularbuild,aggressiveinsports,business SwollenTongueAfterEating Awake,refreshedandreadytogo Totals(OfficeOnly) Bloodpressurefluctuates,high/low Lightheadedfromalyingtostandingposition Emotionalupsetscausecompleteexhaustion Doyouorfamilymembershaveahistoryofauto-immunedisorder?UnusualCravingforSalt Yes NoChronicFatigue Doyouhavesevereallergicreactionstoinsectbites/stings? Totals(OfficeOnly) Yes No Doyouhaveallergicreactionstovaccines/inoculations?

Yes No

G.ImmuneSystemHypo-Activity0123__ H.Urogenital(MalesOnly)0123____ Frequentsorethroats DifficultyUrinating Poorwoundhealing Diminishedsexdrive Getboilsorstyesoften Painoninsidesoflegsorheels Swollenlymphglandsfrequently Feelingofincompletebladderemptying Catchcoldsorflueasily Burningwithurination Slowtorecoverfromcoldsorflu Nighturination Inflamedorbleedinggums Dribblingincontinenceofurine

Totals(OfficeOnly) UrethralDischarge Totals(OfficeOnly)

Haveyouhadprostatetroubleorsurgery? Yes No

0=occurs Never/Rarely 1 = occurs monthly 2 = occurs weekly 3 = occurs daily

I.Endocrine(FemaleOnly)0123__J.Urogenital(FemaleOnly)0123____ Irregularorpainfulperiods FrequentUrination Menstruationisexcessiveorprolonged Burningduringurination Lossofordiminishedsexdrive Frequenturinarytractinfections Feelnervous/depressedbeforeperiods Yeastinfections Menopausalsymptoms UrinaryIncontinence Painfulbreasts White/yellowish/greenishvaginaldischarge Mensesscanty Strongvaginalodor Vaginaldryness Nightsweats

Totals(OfficeOnly) Difficultyurinating Clear,wateryvaginaldischarge

Haveyouhaddifficultyoraninabilitytobecomepregnant? Totals(OfficeOnly) Yes No Haveyouhadyouruterusorovariesremoved? Yes No L.ThyroidFunction 0123__

K.Thyroid,Pancreas,BloodSugarMeta-0123__ Gainweighteasily/failtoloseondieting -bolism,AdrenalGlands,FemaleHormones Frequentconstipation Heartbeatover90beatsperminuteatrest Diminishedsexdrive Protrudingeyeballs Lowpulserate(lessthan60beatsperminute) Nervousness/hyperactivity Depression Insomnia OverEmotional(cryeasily) Noticeabletremorinhands Sensitivetocold Alwaysfeelwarm Fadingmemory/forgetfulness Totals(OfficeOnly) Totals(OfficeOnly)M.Pancreas 0123__ N.BloodSugarMetabolism0123__ Constantintensethirst Nervousness,shakyfeelingorheadaches Visionworseningovershortperiodoftime Irritableifhavelateormissameal Frequenturination Suddencravingforsweets,alcoholorcoffee Breathsometimessmellssweetorlikeacetone HeadachesONLYoccur3-4hoursaftereating Slowhealingofwounds,cutsorabrasions Moodsofdepression,blues,apathy,melancholy Fainting,blackoutsorconvulsions Gethungrysoonaftereating Peculiar,unaccountablesensationsin Heartpalpitatesifmealsaremissedordelayed hands/feetsuchastingling,burning, Totals(OfficeOnly) sharpjabs,numbness Shakinessthatisrelievedbyeating Totals(OfficeOnly) OFFICEUSEONLY:TOTALS0123_ A.HeartandCirculation B.Lungs,NoseandMouth O.CentralNervousSystem0123 C.Stomach,Intestines,Liver&Gallbladder Tremorsofhandsorfeet D.Bones,Joints&Muscles DoubleVision E.AdrenalHyper-Activity SlurredSpeech F.ImmuneSystemHyper-Activity Losingtempereasily,moreemotional G.ImmuneSystemHypo-Activity New,unexplainedheadaches H.Urogenital(maleonly) Partiallossofvision I.Endocrine(femaleonly) Recentlossofcoordination J.Urogenital(femaleonly) Totals(OfficeOnly) K.Thyroid,Pancreas,BloodSugar,Metabolism AdrenalGlands,FemaleHormones

L.ThyroidFunction M.Pancreas N.BloodSugarMetabolism O.CentralNervousSystem

9/11

ClinicPolicyOurpolicyrequirespaymentinfullforallservicesrenderedatthetimeofvisit,unlessotherarrangementshavebeenmadewiththebusinessmanager.Ifyouraccounthasnotbeenpaidwithin90daysofthedateofserviceandnofinancialagreementhasbeenmade,youunderstandthatyouwillberesponsibleforlegalfees,collectionfees,andotherexpensesincurredincollectionsregardingthebalanceofyouraccount.

Iauthorizethestafftoperformanynecessaryservicesneededduringtreatmentandprocedures.Ialsoauthorizetheprovidertoreleaseanyinformationrequiredtoprocessanyinsuranceclaims.

IunderstanditismyresponsibilitytoinformthisofficeofanychangesintheinformationIhaveprovided.IhavereadtheprecedinginformationandcertifyittobetrueandcorrecttothebestofmyknowledgeandherebyauthorizeTheUltimateWellnessCentertoprovidemewithhealthcare,inaccordancewithStatesStatutes.

Informedconsent:IunderstandthattheservicesIamabouttoreceiveareforwellnesspurposesonly.TheUltimateWellnessCenterdoesnotclaimtodiagnose,treatorcureanydiseaseorpathologyincludingcancer.Thishasbeenexplainedtome,IunderstandandknowIcanaskquestions.

PrintName:________________________________________________________________________ Date:__________________________ PatientSignature:___________________________________________________________________ Date:__________________________ ParentorGuardianSignature:_________________________________________________________ Date:__________________________SignatureofHealthcareProvider:______________________________________________________ Date:__________________________

HIPAADeclarationTheClinic:IsrequiredbyfederallawtomaintaintheprivacyofyourPersonalhealthinformation(PHI)andtoprovideyouwiththisprivacynoticedetailingourpractice’slegaldutiesandprivacypracticeswithrespecttoyouPHI.

a. UnderthePrivacyRule,mayrequirebyStatelawtograndgreateraccessormaintaingreaterrestrictionsontheuseorreleaseofyourPHIthanthatwhichprovidedforunderfederallaw

b. IsrequiredtoabidebythetermsofthePrivacyNoticec. ReservestherighttochangethetermsofthisPrivacyNoticeandtomakethenewPrivacyNoticeprovisionseffectiveforallofyourPHI

thatitmaintainsd. WilldistributeanyrevisedPrivacyNoticetoyoupriortoimplementatione. Willnotretaliateagainstyouforfilingacomplaint

PatientCommunications:HealthInsurancePrivacyAct1996requiresweinformyouofthefollowinggovernmentstipulationsinorderforustocontactyouwitheducationalandpromotionalitemsinthefutureviaemail,U.S.mail,telephone,and/orpre-recordedmessages.WeWILLNOTevershare,sell,or“spam”yourpersonalcontactinformation.Marketingisanycommunicationaboutaproductorservicethatencouragesrecipientstopurchaseorusetheproductorservice.CommunicationcanbedefinedasVoiceBlasts,Email,andnumerousmarketingpieces.Communicationstodescribehealth-relatedproductsorservices,orpaymentforthem,providedbyorincludedinabenefitplanofthecoveredentitymakingthecommunication.

a. Communicationsaboutparticipatingprovidersinaproviderorhealthplannetwork,replacementoforenhancements,toahealthplan,andhealth-relatedproductsorservicesavailableonlytoahealthplan’senrolleesthataddvalueto,butarenotpartof,thebenefitplan.

b. Communicationfortreatmentoftheindividualc. Communicationsforcasemanagementorcarecoordinationfortheindividual,ortodirectorrecommendedalternativetreatments,

therapies,healthcareproviders,orcaresettingstoindividuals.

EffectiveDateThisnoticeisineffectasof07/26/2004Bysubscribingmynamebelow,Iacknowledgereceiptofthisnotice,andmyunderstandingandmyagreementtoitsterms_______________________________________________________________________________________________ PatientSignatureDate

10/11

(PersonalInjuryandWorkersCompensationPatientsONLY)

AUTHORIZATIONANDASSIGNMENTTO:AdvancedCareChiropractic,P.A.andCommonSenseWellness

Inconsiderationofyourundertakingtocareforme,Iagreetothefollowing:

1. Youareauthorizedtoreleaseanyinformationyoudeemappropriateconcerningmyphysicalconditiontoanyinsurancecompany,attorneyoradjusterinordertoprocessanyclaimforreimbursementofchargesincurred.

2. IauthorizethedirectpaymenttoyouofanysumInoworhereafteroweyoubymyattorneyoutofproceedsofany

settlementofmycase,andbyanyinsurancecompanyobligatedtomakepaymenttomeoryoubasedinwholeorinpartuponthechargesmadeforyourservices.

3. Intheeventanyinsurancecompanyobligatedbycontractualagreementtomakepaymenttomeortoyouforthe

chargesmadeforyourservicesrefusestomakesuchpaymentupondemandbyyou,Iherebyassignandtransfertoyouthecauseofactionthatexistsinmyfavoragainstanysuchcompanyandauthorizeyoutoprosecutesaidactioneitherinmynameasyouseefitandfurtherauthorizeyoutocompromise,settleorotherwiseresolvesaidclaimasyouseefit.However,itisunderstoodthatuntilallreasonableeffortshavebeenmadetocollectthesumsduefromtheinsurancecompany,orcompanies,contractuallyobligated,youwillrefrainfromattemptsandeffortstocollecttheamountsoweddirectlyfromme.Iunderstandthatwhateveramountsyoudocollectfrominsurancecompanies’proceeds,whetheritbeallorpartofwhatisdue,Ipersonallyoweyou.

4. Inadditiontotheabove,Iherebywaivethestatuteoflimitationsoncollectionand/orrecoveryinthisstateof

Minnesota.5. IfurtheragreethatthisAuthorizationandAssignmentisirrevocableuntilallmoniesowedAdvancedCareChiropractic,

P.A.andCommonSenseWellnessarepaidinfull.Signature:______________________________________________________________________ Date:_____/_____/_______

ACKNOWLEDGEMENTANDUNDERSTANDING

IherebyacknowledgethatIamreceiving(orabouttoreceive)healthcareservicesat,AdvancedCareChiropractic,P.A.andCommonSenseWellness,andthatIhavebeenadvisedthatthedoctor(s)providingtheservicesis/arewillingtowaitforpaymentfortheseservices,providedthattherecontinuestobeareasonablechancethatpaymentwillbemadeeitherbyinsuranceproceedsoroutofthesettlementofaliabilityclaim.Iunderstandthatifitisdeterminedeither:

1. Thatthereisnoinsurancecompanyobligatedtopayforservices,oriftheinsurancecompanyinvolvedrefusesto

acknowledgeanassignmenttoAdvancedCareChiropractic,P.A.andCommonSenseWellness,ormakeotherprovisionsfortheprotectionoftheinterestof;AdvancedCareChiropractic,P.A.andCommonSenseWellness,or

2. Ifaliabilityclaimexists,andmyattorneyrefusestoagreetoprotecttheinterestof,AdvancedCareChiropractic,P.A.and

CommonSenseWellness,orifIhavenotengagedtheservicesofanattorney;thenpaymentforservicesrenderedbyAdvancedCareChiropractic,P.A.andCommonSenseWellness,atAdvancedCareChiropractic,P.A.andCommonSenseWellnesswillbemadeonacurrentbasisandmybillpaidinfullassoonasmyliabilityclaimissettledorthepassageofthreemonthsfrommylasttreatment,whicheveroccursfirst.PatientSignature:___________________________________________________________________ Date:_____/_____/_______

11/11

Notes(FacilityUseOnly)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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