CS{XRSPKACTTC RHffiH$gffiAg'g#ro "&roffi F$$SK#KY

ry\TTENT TNFORMATTON

Date

Patient_,_,Address

City

Sex:flM trrflsingte {ll Married

Zip

,Age___ Birihdate-

fl Wido'r,'ed fl S*parateci [*] Divcrced

Pa{ient SS#

Occupation

Impioyer

Emplcyer

Employer

Spouse's

Birthdate

Address

Phone

Name

ss#

Cccupati*n

Spouse's Employer

Whom may we thank for referring

f:/Lil;-you?

INSURANCE

with

ACCIDENT INFORMATION

ls candition due to an accident? fi yes [] No Date

Type of accide*r flAuro fl Wor.k fl Home i_lOtnerTo whom have you made a reporl of Vour accident?

ll nutc lnsurance I Fmployer f] Wor.ker Comp. f Otrer

Attorney Name (if applicabte)

'cVha is responsible for this account?

Relationship to Patienl

Insurance Co.---.'..-

Group #

ts patient covered by addiiicnai insurance? il yes fj wo

Sirbscriber's iriame

Birthdate

Helationship to Patient ._

insurance Co"

Group #

,A.SSIGNMENT ANO RELEASEl, the unde.signecl ceriifl, lhat I {o, my dependent) har.,e insurance coveraEe

end assign Cirectly t,3

Respcnsitrle Pariy S;gnature

Relali.nship

Dr.-.--_-- aji ;nsu.ance bene{ils, if any,otiler.lise paysfrle io me for sen'ices rendered, I understand thai I am iinanciariy;'esponsible ior ali charg€s trihether of not paid by insurance. I hereby authorizethe doctor to release all inforrftation necessary io secure the paymeni cibenefils- I authorize lfle ils€ of this signatufe on all insurance submjssions.

PHONE NUMBERS

Best time and place to reach you

IN CASE OF FMERGENCY. CONTACT

PATIf,NT CONDITNON

Feason for Visit

When did yorrr symptoms appear?**,_

ls this condition getting prcgressivery worse? [J yes f i'Jo i*] unkncwnMark an X on the picture where you ccniinue io have pain, numbness, or tlngring.Rate the severity of your pain on a scale frorn 1 {least pain) to 10 {severe painj-*_Type of pain: fl Strarp l_l Dutl I lt:ron$ng !---] Nurnbness f]Rcl.:ing ff Shocring

.'-JBurning I Tingring I cran-'ps [] stif'fness l: s**rr;nq il orneiHow often do ycu have this pain?

ls it constant sr does !l come and go?

ntllt rl

f /j \\\(E\l+l6J\fl Iil\ i/ \l \

\t\llJ il1dDoes il interJere wiih yolrr il Work fl Sieep il

Actlviiies cr movemenis that are painfirl to perfcirn

Daily Routine I Recreation

[r] Sftilng fjsranding il Walking L_r iJendtng 1l Lying Down

HSAH.YF{ HSST'#RY

What treatment have you already received {or yaur condition? n Msdications I Surgery [ Fhysical TherapyD Chiropractic Services [] None fl ftner

Name and address o1 other doctor{s) who have tfeated you for your condition

Date of Last: Physical [xaryr____ - _.- spinal x-Ray__ slood restSpinal Fxarn_ Chest X-Rav Urine Te

Dental X-Ray*_ MRl, CT-Scan, Bone Scan

Place a mark on "Yes" or "No" tr: indicate if you have had ar':,r, of the followirrg:

Emphyssrns f] Ves fl t'ic MiscarriageAIDS,/HIV

AlcoholismAllergy ShotsAnemiaAnorexiaAcpendicitisArthritisAsthmaRlaor{inn

DisordersBreast LumpBronbhitisBulimia

'Cancer

CaiaractsChemical

floncnr-iannrr

Chicken PoxDiabetes

f ves I itto

il ves fl trio

fJ Yes [] ttoIYesINoI Yes fl I'to

I Yes fJ tloI Yes f] f.Jc

I Yes [] No

I ves [] tto[J Yes I No

fl Yes fl No

tl Yes [] tuo

fJ yes D r,to

I ves I tto

f]Yes I ttof] Yes [:- ttoI ves I l.to

fl ves f-l r.lo

il Yes [] itto

fl ves f iilo

[f ves I No

f"l Yes X No

ThyrcidProblems

TonsillitisTuberci"rlosis

Tumors,Gi'owlhs

Typhoid FeverUicersVaginal

lnlectionsvEltujgdl

Disease!{hooping

CoughOther

ilYesfNo[] ves il trto

IYesINo

[YesINofJ Yes f No

I ves f trto

IYesilNo

flYes fl ltto

IYesfNc

Epiiepsy I Ves I itlo MononucleosisFractures il Ves f t,to lnuftipleGlaucoma ff Yes il lrJo Scle;'osis

Goiter il Yes I t;o tvlurnPs

Scarlet Fever il Yes fJ ftoStroke il Yes fl I'tcSuicide Attempi I ves il i*o

IYesfrucil Yes tl rur:

Gonorrhea I Yes ! No 0steoPorosis

Gaut [-] Yes I No Pacemaker

Heart Disease fl yes f] t to Parkrnson's

i-repariiis tf Y*' - hr; ,t:;:;-l$.,'_ il;::= il:Hei'nia I yes [] iuo ,;ffi; Ll yes [_i NoHerniated Disk I Yes i] No p;; " -

[] yes f NoHer.pes [] -ves L] No -:^'-_"Hish : 'f?::ff:"- ;yes[hicChulesterol I fes i_'l No fro"tn*rio I yes I NoKidney Disease [*] ves LJ t to p-v.ni-ui_ care lJ yes f_l NoLiver Disease I v,es I trio nif"r"t" aMeasles [J Yes [] No A*hriris

- [ Ves I t,to

MigraineHeadaches IYesINo

flheurnaticFever

}*AEITS

I Smoking

il Alcohol

ll Coffee/Caffeine Drinks

l*l Higir Stress Level

PacksiDay.

DrinksArVeek

CupslDay

Feason

Are you pregnant? ll Ves I No Due Date

lnjurieslSurgeries you have had llescription

EXERCISE

f None

fl Moderate

L,l uarry

1-*l Heavy

WORK ACTIVITYil sitting

il Standing

f Lignt Labor

fl Heavy Labor

Fatl.s

Head Injuries

Broken Bones

Dislocations

Surgeries

&THNECATX*1\5 AX.X,ilH.GXfi5

Pharrnacy Name

Pharmacy Phorre

7

Patient Health Questionnaire - PHCIACN Group. Inc. - Form PHQ-202

Patient Name Date

1. Describe your symptoms

a. When did your symptams start?

b. How did your symptoms begin?

2. How often do you experience your symptoms? lndicate where you have pain or other symptomsO Constantly (76-100% of the day)

@ Frequently {51-75% of the day)

@ Occasionally {26-54% of the day)

@ lntermittently (0-25% of the day)

3. What describes the nature af your symptoms?O Sharp O Shooting

t:!:.@ Dullache @ Burnins

CI Numb @ Tingling

4" How are yaur syrnptoms changing?O Getting Better@ Not Changing

@ Getting Worse

5. During the past 4 weeks:

a. Indicate the average intensity of your symptoms

b. How much has pain interfered with your norma! work (inctuding both work oulside the home. and housework)

o Not at ail @ A litile bit @ Moderately @ Quite a bii @ Extremeiy

6. During ffie pasf 4 ureeks how much sf the time has yeur condition interfered with yaur social activities?(like visiting with friends, relatives, etc)

OAllof thetime @Mostof thetime @someof thetime @ Alitileof thetime 5r Noneof thetime

7. ln general would you say your overall health right now is...

O Excellent @ Very Good @ Good

8. Who have you seen for yaur symptoms? O No One@ Chiropractor

a. What treatment did you receive and when?

b. What fes/s fuaye you had for your sympfornsanti when were thev oerformed?

9. Have you had similar symptoms in the past?

a. lf you have received treatment in the past forthe same or similar symptoms, who did you see?

10. What is your occupation?

a. lf you are nat retired, a hamemaker, ar astudent. what is vour current work status?

r!i' I

il

:\ ll..i

il'

None Unbearabie@o@o@@@o@o@

@ Fair @ Poor

@ MedicalDoctor @ Other@ PhysicalTherapist

,1CiV Croi/o, i6c. Use Only ,?r 7,18/15

:-.t

:

I

I

ilr, . !,i \,r

li

\ :; /1.", i

' !t i

O Xrays date;

O n\,4R1 darc:

OYes

O This Office@ Chiropractor

O Professional/Executive@ White Collar/Secretarial@ Tradesperson

FuiltimePart-time

@ Other date:

ONo

@ MedicalDoctor@ PhysicalTherapist

@ Laborer@ Homemaker@ FT Student

@ Other

O Retired@ Other

AUo\

@ Seli-employed @ Off work@ Unemployed @ Other

DatePatient Signature

a

Neck lndexACN Group, Inc. Form Nl-100

Patient Name Date

This questionnaire will give your provider information about how your neck condition affects your everyday tife.Please answer every secflon by marking the one statement that appties to you. lf two or more statemenfs in onesection apply, p/easb mark the-one statiment thatmosf close Iy d6scnbes yair probtem.

Pain lntensity@ | have no pain at tf€ moment.

O The pain is very mild at the moment.

@ The pain comes and goes and is rnoderate.

@ The pain is fairly severe at the moment.

@ The pain is very severe at the moment

@ The pain is the worst imaginable at the moment.

Sfeeprng@ | havenotrouble sleeping.

O My steep is slightly disturbed (less than t hour sleepless).

@ My sleep is mildly disturbed (1-2 hours sleepless).

@ My sleep is moderately disturbed (2-3 hours sleepless).(} My sleep is greatty disturbed ($5 hours sleepless).

@ My sleep is completely disturbed (S-7 houns sleepless).

Reading@ | can read as much as I want with no neck pain.

O I can read as much as I want with slight neck pain.

@ tcan read as much as lwantwith nmderate neck pain.

@ I cannot read as much as I want because of moderate neck oain.@ I can hardty read at all because of severe neck pain.

@ | cannot read at all because of neck oain.

ConcentrationI can concentrate fully when lwant wih no difficutty.

I can concentrate fully when I want with slight difficulty,I have a fair degree of dfficulty concentrating wtren lwant.I have a lot of dfficulty concentrating when I want.I have a great deal of difficulty concentrating when twant.I cannot concentrate at all.

Work@ I can do as rnuch work as I want.

O I can only do my usual work but no more.

@ I can only do most of my usual work but no more

@ | cannotdo my usualwork.

@ I can hardly do any work at all.

@ | cannot do any work at al,.

Personal Care@ | can look after myself normally witrout causing extra pain.

O I can look after mysetf normally but it causes extra pain.

@ lt is painful to look after myself and I am slow and careful.

@ | need some help but I manage most of my personal care.

@ | need help every day in most aspecb of self care.

@ | do not get dressed, I wash with diffictlty and stay in bed.

Lifting@ I can lift heavy weighb without extra pain.

O I can lift heavy weights but it causes extra pain.

@ Pain prevents me from lifiing heavy weights off he floor, but I can rnanageif they are conveniently posilioned (e.g., on a table).

@ Pain prarents me fionr liffing heavy weights off the floor, but I can managelight to rnedium weights if they an convenienily positioned.

@ I can only lift very light weights.

@ | cannot lift or carry anything at all.

Driving@ I can drive my car wittrout any neck pain.

O I can drive my car as long as I want with slight neck pain.

@ | can drive my car as long as I want with moderate neck pain.

@ | cannot drive my car as long as I want because of moderate neck Dain.

@ t can hardly drive atall because of severe neck pain.

@ | cannotdrive my caratall because ofneck oain.

Recreation@ Iam able to engage in all my recreation aelivities without neck Dain.

o I am able to engage in a[ my usuar recreation activities with some neck pain.

@ | am abb to engage in nrost but not all my usual recreation aclivfies beeuse of neck narn.@ | am only abb to engage in a fer,rr of my usual reueation activities because of neck pain.@ i can hardly do any recreation activities because of neck oain.@ I cannot do any recreation activities at all.

Headaches@ I have no headaches at all.

O I have slight headaches whici come infrequenily.

@ I have moderate headaches which come infrequently.

@ | have moderate headaches which come frequenfly.

@ | have severe headaches which come frequently.

@ I have headaches almost all ihe time.

@o@@@@

ACN GDup. lnc. tJse Onty rev 3/27/2003

tre"* [-_ltndex | |

Score I I!q"I999t":f!m ,f all statements selected / (# of sections with a statement selected x 5)l x

Back lndexACN Group, Inc. Form Bl-100

Patient Name

Pain lntensity@ The pain comes and goes and is very mild.

O The pain is mild and does not vary much.@ The pain comes and goes and is moderate.@ The pain is moderate and does not vary much.@ The pain comes and goes ard is very severe.@ The pain is very severe and does not vary much.

Sleeping@ lget no pain in bed.

O I get pain in bed bui it does not prevent me from sleeping r*ell.@ Because of pain my normal sleep is reduced by less than 25%.@ Because of pain my normal sleep is reduced by less than S0%.@ Because of pain my normal sleep is reduced by less than 75%.@ pain prevents me ftom sleeping at all.

Sitting@ I can sit in any chair as long as I like.

O I can only sit in my favorite chair as long as I like.@ Pain prevents rne from sitting more than f hour.

@ Pain prevents me from sitting more than 1i2 hour.@ Pain prevents me from sitting more than 10 minutes.@ | avoid sitting because it increases pain immediatelv.

Standing@ | can stand as long as I want without pain.

O I have some pain while standing but it does not increase with time.@ | cannot stand for longer than t hour without increasing pain.@ | cannot stand for longer than 1/2 hour without increasing parn.

@ I cannot stand for longer than 10 minutes without increasing pain.

@ | avoid standing because it increases pain immediatelv.

Walking@ I have no pain while walking.

O I have some pain while walking but it doesn't increase with distance@ | cannot walk more than 1 mile without increasing pain,@ | cannot walk more than 112 mile without increasing pain.

@ | cannot walk more than 1/4 mile without inueasing pain.

@ | cannot walk at all without increasing pain.

Date

Personal Care@ I do not have to change my way of washing or dressing in order to avoid pain.o I do not normally change my way of washing or dressing even though it causes some pain.@ washing and dressing increases the pain buil manage not to change my way of doing rt.@ washing and dressing increases the pain and | find itnecessary to change my way of doing it.@ Bmuse of the pain I am unabre to do some washing and dressing without herp.

'

@ Because of the pain I am unable to do any washing and dressing without help.

Lifting@ | can lift heavy weights wihout extra oain.

@ I can lift hearry weights but it causes extra pain.

@ Pain prevents me from lifting heavy weights off the floor.

@ Pain preveftts me ftom liffing heavy weights off the floor, but I can manageif they are convenienfly positioned (e.g., on a table).

@ Pain prevents me from lifiing heavy weights ofi be floor, but I can manage, light to medium weights if they are convenienfly positioneo.@ | can only lift very light weights.

Traveling@ | get no pain rvhite traveling.

o I gei some pain while traveling but none of my usual forms of travel make it worse.@ t get exta pain wrrile traveling but it does not cause me to seek anemate furms of Favet.@ | get extra pain while traveling which causes me to seek altemate forms of travel.@ Pain restricts atlforms of travel except that done while lyng down.@ Pain restricts all forms of traver.

Socraf LrTe

@ My social life is normal and gives me no extra oain.@ My social life is normal but increases the degree of pain.

@ Pain has no significant affect on my social life apart from tirniting my moreenergetic interests (e.9., dancing, etc).

@ pain has restricted my social lib and I do not go out very often.@ Pain has reshicted my social life to my home.

@ | have hardly any social life because of the pain.

Changing degree of pain@ My pain is rapidly geting better.

O My pain fluctuates but overall is definitely getting better.@ lity pain seems to be gefting better but improvement is stow.@ My pain is neither getting better or worse.@ My pain is gradually worsening.

@ My pain is rapidly worsening. Back

rhis quesflonnaire will give your prottider information about how your back condition affecfs your everyday life.P/ease answer every section. by marking the one statement tnat'api,tieii, ioi.-'tr t*" or moresfalemenfs in anesection appty, p/easb mark the'one staiment that most ctosety d;;cibe; ;;;; p,robtem.

ACN GDrp. tnc. lJse Onty rcv 3/Z7fz0o3

[]LL49l tggt" = tg-qt:t all statements selected | (# of sections with a statement setected x 5)l xlndexScore