DR. CAROLYN DAVIS-WILLIAMS, D.C. 2408 Wheeler St. Houston, TX 77004

ADVANCED CHIROPRACTIC CLINIC (713) 529-6760 Clinic (713) 526-0655 Fax

PERSONAL INJURY QUESTIONNAIRE

Name Phone (H/C) Phone ( W ) .

Address City State Z i p .

Email ^Sex • M • F Birth Date SS#

Emergency Contact Name Relationship P h o n e .

Your Ins. Co. Policy # Claim # P h o n e .

Name on Policy (If other than self) Relationship Agent's N a m e .

Responsible Party's Name Ins. Co. Policy #

Claim # Phone Policy Holder's Name

NATURE OF ACCIDENT:

1 . Date of Accident T ime of D a y .

Address City State Zip .

ATTORNEY

Name Phone Fax

Address City State Z i p .

W e r e there any w i t n e s s e s ? • Yes • No If yes. Name (s)

2. Were you: • Driver • Passenger • Front Seat • Back Seat

3. Number of people in your vehicle? W e r e you wearing seat belt? • Yes • No W e r e you wearing shoulder harness? • Yes • No

4. W h a t direction w e r e you headed? • North • East • South • West on (name of street)

5. W h a t direction w a s the car that struck you headed? • North • East • South • West on (name of s t r e e t ) .

6. W e r e you struck f r o m ; • Behind • Front • Left side • Right side

7. Approximate speed of your car? mph Other car? mph

8. W e r e you knocked unconscious? • Yes • No If yes, for how long?

9. W e r e police notified? • Yes • No

10. In your own words, please describe accident: ,

1 1 . Did you have any physical complaints BEFORE THE ACCIDENT? Yes No If yes, please describe in detai l :

12. Please describe how you felt:

a. DURING the accident:

h, IMMEDIATELY AFTER the accident:

c. U T E R THAT DAY:

d. THE NEXT DAY:

Doctor's Signature:

DR. CAROLYN DAVIS-WILLIAMS, D.C. 2408 Wheeler St. Houston, TX 77004

ADVANCED CHIROPRACTIC CLINIC (713) 529-6760 Clinic (713) 526-0655 Fax

13. What are your PRESENT complaints and s y m p t o m s ? .

14. Do you have any congenital ( from hirth) factors which relate to this problem? • Yes • No If yes, please descr ibe: .

15. Do you have any previous Illnesses which relate to this case? • Yes • No If yes, please describe:.

16. Have you ever been involved in an accident before? • Yes • No

wel l as injury (les) received:

If yes, please describe, including date(s) and type(s) of accidents, as

17. W h e r e w e r e you taken after the a c c i d e n t ? .

18. Have you been t reated by another doctor since the accident? • Yes • No If yes, please list doctor's name, address and phone: _

W h a t type of t r e a t m e n t did you r e c e i v e ? .

19. Since this injury occurred, are your symptoms: • Same • Improving •Gett ing Worse

20. CHECK S Y M P T O M S YOU HAVE NOTICED SINCE ACCIDENT:

• Headache • Neck Pain • Neck Stiff • Sleeping Problems • Back Pain • Nervousness • Tension

Symptoms Other t h a n Above:

D Irritahllity a Chest Pain • Dizziness • Head Seems Too Heavy • Pins & Needles in Arms • Pins & Needles in Legs • Numbness in Fingers

• Numbness in Toes • Shortness of Breath • Fatigue • Depression • Lights Bother Eyes • Loss of Memory • Ears Ringing

• Face Flushed • Buzzing in Ears • Loss of Balance • Fainting • Loss of Smell • Loss of Taste • Diarrhea

• Feet Cold • Hands Cold • Stomach Upset • Constipation • Cold Sweats • Fever • Other (list below)

2 1 . Have you lost t ime f rom work as a result of this accident? • Yes • No

a. Last Day W o r k e d ?

If yes, please complete t h e s e questions:

b. Type of E m p l o y m e n t ? .

c. Present Salary?

d. Are you being compensated for t ime lost f rom w o r k ? D Y e s • No

If yes, please state type of compensation you are receiving: _

22. Do you notice any activity restrictions as a result of this injury? • Yes • No If yes, please describe in detai l : .

2 3 . Other pertinent information:

PRINT NAME SIGNATURE DATE

Doctor's 5ignature:

C A R O L Y N DAYIS-WILLIAMS, D.C. -- ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax PATIENT PERSONAL, F A M I L Y & SOCIAL HISTORY Date Information contained herein w i l l not be released except as you have authorized and w i l l be used by your doctor in decisions regarding your care, so please answer all questions honestly and to the best of your knowledge.

Last Name:_ First Name:_ M ^ W4 D

Middle: .Age:_

Stroke

Hay Fever

Bleeding Tendency

Bronchitis

Seizures

Diabetes

Kidney Disease

Leukemia

Rheumatic Heart

Migraine

Tuberculosis

Thyroid Problems

Bladder Infection

Arthritis

Tonsillitis

Broken Bones

Congenital Heart

Asthma

Blood Clots

High Blood Pressure

Anxiety or Depression

High Cholesterol

AIDS/+H1V

Depression

Ht: Marital Status: S d M^ D<̂ Separated i Sex: 4 M Do you have or have you had: Please arcle all tliat apply ( I f yes, give date of occurrence)

Colitis

Diarrhea

Pneumonia

Cancer

Heart Attack

Stomach Ulcers

Glaucoma

Anxiety

Wt:

Sleep Apnea

Excessive Drowsiness

Loud Snoring

Shortness of Breath

Chest Pain

Heart Failure

Gallstones

Suicide Attempt

Is this vis i t as a result o f an injury or accidents: Auto_ Other Type o f Injury: Describe Details

Date Work Related Date Date

Primary Reason for T h i s V i s i t ? D') _

2"")

Date o f Onset

3 ' " ) . 4 t h ) .

Have you had treatment for this condition? Y N I f so What?

Doctor 's Name: Speciality: When Seen? Dr. Phone Number:

P A I N L E V E L T O D A Y (0 N O P A I N / 10 W O R S T P A I N E R ) I 2 3 4 5 6 7 8 9 10 ( W O R W / O M E D S )

Type o f Pain/Condition? Dul l * Ach ing * Sharp * Burning * Throbbing * Nagging * Numbness * Tingl ing * Radiate * Move Around

Name and Dates o f a l l operations you have had; .

Name any drugs to which you are allergic: .

Serious illnesses you have had: .

Serious injuries or accidents: . A R E Y O U P R E S E N T L Y T A K I N G A N Y O F T H E F O L L O W I N G M E D I C A T I O N S ? Aspirin, A d v i l , Anac in Laxatives Seizure medicine Blood pressure pil ls

Sleeping pills Shots Cortisone Thyroid medicine

Water pil ls Chough medicine Headache pills Antibiotics

Digitalis Medicine for arthritis Cold medication Hormones

Tranquilizers Bir th control pil ls Insulin or diabetic pills Weight reducing pil ls

Pain medicine Iron Poor blood medication Blood thinning pills

Over the counter med Vitamins Medicine for depression E y e drops *

Ulcer medicine Cholesterol medicine Other drugs not listed Other medicine Please check all that apply:

Y E S ^ NO ^ I f you smoke or have you ever smoked. H o w much?_ Date of last chest X - R a y YES 4 m4

YES 4 m4 Y E S ^ N O ^ Y E S ^ NO Y E S < ! N O d

H o w many years? I f quit, when?_

Do you usual ly d r ink over 6 cups of caffeinated beverages per day?_ Do you regularly drink alcohol, wine, or beer? How much? Do you exercise regular ly? Wha t and H o w Often? Do you sleep we l l ? Mattress Age

DOCTOR'S SIGNATURE D A T E

CAROLYN DAYIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax Please check a l l that apply: Continued Confidential Personal History Page Two

YES 4 YESi

YES 4 YES 4 YES 4 YES 4 YES 4 YES 4 YES 4 YES 4

NO . N O . N O . NO . NO . N O . NO NO NO NO

Do you have pets? B i rds _ C a t s _ D o g s _ Other . Do you use recreat ional drugs? W h a t . Do you eat regular ly? T i m e s a Day? 1_ 2 _ 3 Do you have regular recreat ion t ime? Type?_

. Healthy? Healthy Sometimes? Fas t Food? .

Do you spend t ime in Nature or Fun? Beach _ Fish ing _ Golf_ L a k e s , T e n n i s , W a l k i n g ,Other , What type of w o r k do y o u perform? W o r k Schedule Are you a student? Y N Elementary _ Middle School _ High School _ College. Do you have many friends? Wha t do you do w i t h them? Do you vacation? Where? W h e n last t ime? Do you v is i t the country or farms? When? When do you feel the best? W o r s t .

Highest l e v e l .

Pet or See F a r m An ima l s Y N

F O O D S / D R I N K S • 1 Artif icial Sweeteners Crave Salt or Sugar Fas t Foods, How Often, Food Types Eaten Daily? Bread / Pasta / F i sh / Red Meat / Fruie / Vegtables • Sweets How Often? • Meals Eaten Per Day? T imes in the Day • Energy D r i n k s H o w Often? • Sodas Regular or Diet How Often? • Water How Much Daily?

W O M E N O N L Y

YES 4 YES 4 YES 4 YES 4 YES 4 YES 4 YES 4 YES 4

NO NO NO NO NO NO NO NO

A r e you NOW pregnant? A r e you having regular monthly menst rual cycles? I f Yes Las t cyc le? . I f not, are you having symptoms of the menopause? Have you ever had bleeding between your cycles? When? Do you have v e r y heavy bleeding w i t h your cycles? When? Have you ever or do you now had any vaginal infections? When? Are you now or have you ever taken b i r th control pi l ls? When? Do you now or ever and a hernia? Where? ^ Surgery repa i r? .

Date of las t pap smear tes t . Results H o w many? Children born a l i v e ? . A n y complicat ions of pregnancy?,

M E N O N L Y

. Miscarriages? St i l lbir ths? C-Sections? Premature b i r t h s ? .

Y E S ^ NO YES 4 NO YES 4 NO YES 4 NO

Any of your blood

4 Have you ever had problems w i t h your testicles or scrotum? 4 Have you ever had a discharge from your penis? 4 Do you now or ever and a hernia? Where? Surgery r epa i r ? .

Have you had trouble w i t h your prostrate [u r ina ry frequency, hesitancy, or dr ibble)? relatives have or had: Please circle all that apply ( i f yes, give date o f occurrence and relationship)

stroke

Hay Fever

Bleeding Tendency

Bronchitis

Seizures ^ | ^ ^ |

Diabetes

Kidney Disease

Glaucoma

Rheumatic Heart

Migraine

Tuberculosis

Thyroid Problems

Bladder Infection

Arthritis

Tonsillitis

Gall Stones

Congenital Hea t

Asthma

Blood Clots

High Blood Pressure

Anxiety or Depression

High Cholesterol

A1DS/+HIV

Leukemia

Colitis

Diarrhea

Pneumonia

Cancer

Heart Attack

Stomach Ulcers

Heart Failure

Suicide Attempt

I H E R E B Y A U T H O R I Z E C A R O L Y N D A V I S - W I L L I A M S , D.C. T O A P P L Y T O M Y PIP /MEDPAY OR T H I R D P A R T Y I N S U R A N C E C A R R I E R , FOR B E N E F I T S ON M Y B E H A L F FOR C O V E R E D S E R V I C E S R E N D E R E D B Y DR. W I L L I A M S . I R E Q U E S T T H A T P A Y M E N T F R O M M Y PIP /MEDPAY OR T H I R D P A R T Y I N S U R A N C E C A R R I E R B E M A D E D I R E C T L Y T O DR. W I L L I A M S . I A G R E E T O P A Y FOR A N Y S E R V I C E S NOT P A I D B Y M Y INSURANCE. T H E O F F I C E W I L L A S S I S T M E AS M U C H AS P O S S I B L E T O G E T T H E C A R R I E R T O P A Y M Y C L A I M S , H O W E V E R , T H E C O N T R A C T IS B E T W E E N M E AND T H E I N S U R A N C E C A R R I E R . SO I R E A L I Z E T H A T P A Y M E N T FOR M Y H E A L T H C A R E IS M Y S O L E R E S P O N S I B I L I T Y . I P E R M I T A C O P Y OF T H I S A U T H O R I Z A T I O N T O B E U S E D IN P L A C E OF T H E O R I G I N A L . T H I S A U T H O R I Z A T I O N A P P L I E S T O A L L OCCASIONS OF S E R V I C E U N T I L R E V O K E D B Y M E IN W R I T I N G .

1 A U T H O R I Z E T H E R E L E A S E OF A N Y M E D I C A L INFORMATION N E C E S S A R Y TO PROCESS TO M Y P I P / M E D P A Y OR T H I R D P A R T Y INSURANCE C L A I M S U B M I T T E D B Y T H E C L I N I C . I P E R M I T A C O P Y OF THIS A U T H O R I Z A T I O N T O B E U S E D IN P L A C E OF T H E O R I G I N A L . I A L S O G I V E DR. W I L L I A M S PERMISSION T O R E L E A S E D E M O G R A P H I C INFORMATION TO HOSPITAL, L A B O R A T O R I E S , A N D R A D I O L O G Y AS N E E D E D TO S C H E D U L E T E S T S OR O T H E R M E D I C A L P R O C E D U R E S FOR ME.

P A T I E N T ' S S I G N A T U R E D A T E

DOCTOR'S SIGNATURE D A T E

C A R O L Y N DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

R E V I E W OF SYSTEMS P A T I E N T S N A M E D A T E CARDIOVASCULAR: • Angina • Ankle Swelling • Awakening At Night • Cardiac Catheterization • Chest Pains • Congenital Heart Defects • Cold Hands or Feet • Dizzy When Standing Quickly • Heart Attacks • Heart Failure • Heart Murmurs • Heart Palpitations • High Blood Pressure • Low Blood Pressure • Irregular Heart Rate • Leg Cramps • Leg Pain That Stop with Rest • Nigh* Sweats • Pain Left Side Arm/Face/Neck • Pounding Heartbeat • Rapid Heartbeat • Purple Fingers or Lips • Short of Breath • Varicose Veins

EARS. & EYES, n Ear Aches • Ear Discharge • Ear Infections • Ear Pain • Hearing Loss • Ringing In Ears • Cataracts • Double Vision • Eye Problems • Glasses/Contacts • Glaucoma • Itchy, Red or Watery • Night Vision Poor • Pain In, Behind, Near

ENDOCRINE • Abnormal Blood Counts • Anemia • Arthritis • Changes In Skin Texture • Diabetes • Decrease/Increased Body Hair • Decrease/Increase Facial Hair • Decrease Head Hair (not male baldness) • History of "Borderline" Diabetes • Flushing / Hot Flashes • Intolerance Cold • Intolerance Heat • Sickle Cell

GASTROINTESTIONAL •Abdominal Pain • Anal Fissures • Belching • Intestinal Bloating •Gas/Flatulence • Black Tarry Stools •Constipation • Diarrhea • Feel Fatigue or Lethargic After Eating • Gall Stones • Heart Burn • Hiatal Hernia • Hemorrhoids • indigestion • Intestinal Obstruction • Liver Disease • Loss of Bowel Control • Nausea • Pain in Stomach, Intestines or Colon • Poor Digestion • Problems Swallowing • Red Blood After Bowel Movement • Rectal Bleeding, Itching or Bleeding • Reflux • Ulcers • Vomiting Blood • Vomiting

GENERAL • Appetite Increased / Decreased • Binge/ Compulsive Eating • Change In Activity • Change In Sleeping Patterns • Excessive Tiredness • Enlarged Lymph Nodes • Fatigue (lack of energy or stamina) • Frequent Infections • Hypoglycemia (Low Blood Sugar) • Increased Need for Sleep • Insomnia • Tired or Not Hungry When Waking • Weight Gain • Weight Loss

KIDNEYS & URINARY TRACT • Bladder Problems • Blood In Urine • Brown Urine • Dribbling After Urination • Excessive Thirst • Frequent Bladder Infection • involuntary Urination • Kidney Disease • Kidney Stones • Painful (or Burning) Urination

• Urination Frequency (Day) • Urination Frequency (Night) • Urine Hesitancy • Urinary Incontinence • Urinary Tract Infections (UTI) • Weak Flow

LUNGS •Asthma • Blood Clots in Lungs •Bronchitis •Coughing •Chest Congestion •COPD

MOUTH. NOSE. TEETH & THROAT • Decrease taste / smell • Gum Problems • Oral Herpes • Sores Mouth / Lips • Swollen / Tender Tongue / Gums • Swollen Glands • Allergies to Animals , Food , Environment/Chemicals • Hay Fever • Nose Bleeds Freq • Nasal Polyps • Nose Runs • Sinus Infections • Sinus Pain • Bad Breath • Dentures • Regular Dental Check-ups • Mercury fillings • Root Canals • Coughing • Drainage • Excess Mucus • Goiter • Hoarseness • Polyps • Sore Throats • Swollen Glands • Voice Changes MUSCULOSKELETAL • Areas of numbness • Areas of Pain • Areas of Tingling • Back Pain • Blood Clots in Legs • Bone Marrow Biopsy • Bursitis • Easy Bleeding • Easy Bruising • Gout • Joint Aches • Joint Pain • Joint Swelling • Limited Motion in Joints • Morning Stiffness • Muscle Aches/Pain • Muscle Weakness • Muscle Cramps • Neck Pain • Night Pain • Tendonitis

NEUROLOGICAL • Anxiety • Blackouts • Change in Sensation On Your Body •Confusion • Depression • Difficult In Talking • Dizziness • Epilepsy • Fainting Spells • Headaches • Head Injuries •Hyperactivity • Learning Difficulty • Loss of Consciousness • Memory Loss • Meningitis • Near Blackouts • Paralysis • Pressure feeling in Head • Seizures • Strokes • Tingling • Tremors • Weakness or Numbness

RESPIRATORY • Asthma • Breathlessness When Lying Flat • Coughing Up Blood • Emphysema • Frequent Bronchitis • Pleurisy • Pneumonia • Prolonged Cough • Shortness of Breath • Tuberculosis • Wheezing

SKIN & NAILS • Abscess •Acne •Athlete's Foot •Boils • Change in Skin Color •Dandruff • Dry Skin / Oily Skin • Eczema • Excessive Body Odor • Excessive / Not Sweating • Fungal Infections • Hives • Itchy Skin W or W/O Redness • Jaundice • Lumps • Moles - Change • Moles - irregular • Moles New • Psoriasis • Rashes • Small Rough Bumps on Skin • Nail Problems • Weak Nails • Ridged Nail

MALE & FEMALE • Genital Herpes • Groin Itching • Loss of Sexual Interest • Painful Sexual Intercourse • Sexually Transmitted Disease (STD) • Tested for HIV Y N • Unprotected Sex

MALES ONLY • Bloody Ejaculation • Family History of Prostate Cancer Y N • Hernia • Inability to Complete Intercourse • Lump On Testicle • Penile Discharge • Problems Maintaining or Keeping Erection • Prostate Disease • Slow Urine Stream • Sores on Penis • Sterility • Testicular Pain • Testes Undescended, In Abdomen or Pelvis • Testicular Swelling • Warts on Penis

FEMALES ONLY • Abnormal Bleeding Between Cycles • Abnormal PapTest • Bleeding After intercourse • Complications With Pregnancy • D&C • Discharge From Breast • Endometriosis • Excessive Bleeding • Fibroids • Heavy Bleeding During Cycles • Hernia • Hot Flashes • Infertility • irregular Periods • Pain in Breasts • Painful Periods • Pain Between Periods • Ovarian Cyst • Pelvic Inflammatory Disease • Post-Menopausal Symptoms • (PMS) • Vaginal Discharge • Vaginal Dryness • Vaginal Warts •WaterRetention •YeastInfections

DOCTOR'S SIGNATURE D A T E

Patient Questionnaire Patient Name

This questionnaire consists of 21 groups of statements. After reading each group of statements carefully, circle the number ( 0 , 1 , 2, or 3) next to the one statement in each group which best describes the way you have been feeling the past week, including today. If several statements within a group seem to apply equally well, circle each one. Be sure to read ail the statements in each group before making your choice.

1. 0 I do not feel sad. 1 I fee sad. 2 I am sad all the time and I can't snap out of it. 3 I am so sad or unhappy that I can't stand it,

2. 0 I am not particularly discouraged about the future. 1 I fee discouraged about the future. 2 I feel I have nothing to look forward to. 3 I fee that the future is hopeless and that things

cannot improve.

3. 0 I do not feei like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of

failures. 3 I feel I am a complete failure as a person.

4. 0 I get as much satisfaction out of things as 1 used to. 1 I don't enjoy things the way I used to. 2 I don't get real satisfaction out of anything. 3 I am dissatisfied or bored with everything,

5. 0 I don't feel particularly guilty. 1 I feel guilty a good part of the time. 2 I feel quite guilty most of the time. 3 [,feel guilty all of the time.

6. 0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished.

7. 0 I don't feel disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself.

8. 0 I don't feel I am any worse than anybody else. 1 I am critical of myself for my weaknesses or

mistakes. 2 I blame myself all the time for my faults. 3 I blame myself for everything bad that happens.

9. 0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not

carry them out. 2 I would like to kill myself. 3 I would kill myself if 1 had the chance.

10. 0 I don't cry anymore than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I used to be able to cry, but now I can't cry even

though I want to.

11. 0 I am no more Irritated now than I ever am. 1 I get annoyed or irritated more easily than I used to. 2 I feel irritated all the time now. 3 I don't get irritated at all by the things that used to

irritate me.

12. 0 I have not lost interest in other people. 1 I am less interested in other people than 1 used to

be. 2 I have lost most of my interest in other people. 3 I have lost all interest in other people.

13. 0 I make decisions about as well as I ever could. 1 I put off making decisions more that I used to. 2 I have greater difficulty in making decisions than

before, 3 I can't make decisions at all anymore.

14. 0 I don't feel I look any worse than I used to. 1 I am worried that I am looking old or unattractive. 2 I feel that there are permanent changes In my

appearance that make me look unattractive. 3 I believe that I look ugly.

15. 0 I can work about as well as before. 1 It takes an extra effort to get started at doing

something. 2 I have to push myself very hard to do anything. 3 I can't do any work at ail.

16. 0 I can sleep as well as usual. 1 I don't sleep as well as I used to. 2 I wake-up 1-2 hours earlier than usual and find it

hard to get back to sleep. 3 1 wake-up several hours earlier than I used to and

cannot get back to sleep.

17. 0 I don't get mora tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing almost anything. 3 I am too tired to do anything.

18. 0 My appetite is no worse than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore.

19. 0 I haven't lost much weight, if any lately. 1 I have lost more than 5 pounds. 2 I have lost more than 10 pounds. 3 I have lost more than 15 pounds.

20. 0 i am no more worried about my health than usual. 1 I am worried about physical problems such as aches

and pains; or upset stomach; or constipation. 2 I am very worried about physical problems and it's

hard to think of much else. 3 I am so worried about my physical problems that I

cannot think about anything else.

21. 0 I have not noticed any recent changes in my interest in sex.

1 1 am less interested in sex than I used to be. 2 I am much less Interested in sex now. 3 I have lost interest in sex completely.

CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

CHIROPRACTIC INFORMED CONSENT The doctor after examination has explained the prescribed treatment plan to me (for myself or for my minor child) including the nature and purpose of the chiropractic adjustments as well as other treatments or procedures appropriate for the condition. I hereby request and consent to treatment from ADVANCED CHIROPRACTIC CLINIC, P.C. doctors and staff including chiropractic adjustments, manual therapy techniques and physical modalities including hydroculation (heat), cryotherapy (ice), ultrasound, neuromuscular reeducation, massage, rehah, examinations or other treatments and testing that the doctor determines to he appropriate for my condition or for my minor child's condition.

In particular you should note: a) While rare, some patients have experienced rib fractures, muscle strains and/or ligament sprains following spinal

manipulation. b) There have been reported cases of injury to a vertebral artery following cervical spinal adjustments. Vertebral

artery injuries have been known to cause stroke, sometimes with serious neurological impairment, and may on rare occasion result in death.

c) Hydroculation (heat) and cyrotherapy (Ice): skin reactions or burns

Chiropractic treatments, including spinal adjustments, have been the subject of government reports and multi-dlscipiinary studies conducted over many years and have been demonstrated to he highly effective treatment for spinal pain, headaches being and other similar symptoms. The risk for injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

I acknowledge I have discussed, or have had the opportunity to discuss, with my doctor the nature and purpose of the treatments in general and myself or my minor child's treatment in particular (including spinal adjustments) as well as the contents of this Consent and I fully understand that there are no guarantees in medicine as to the outcome of any treatment. I consent to the treatment offered or recommended to me for myself or my minor child including spinal adjustments. I intend this consent to apply to all of my or my minor child's present and future care.

I understand and am Informed that, as with any medical treatment and care. In the practice of chiropractic there are some risks. I do not expect the doctor to he able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of treatment and procedures that the doctor feels appropriate for me at the time based on the facts know at the time, in my or my minor child's best interest.

I have read (or have read to me) the above consent. I have had an opportunity to ask any questions I had about its content, and by signing below I agree to begin treatment for myself or for my minor child, .

I intend this consent form to cover the entire course of treatment for myself and/or my minor child's present condition and for any future condition (s) for which I may continue to seek treatment here at ADVANCED CHIROPRACTIC CLINIC, P.C.

Patient Printed Name Patient Signature Date

Witness Printed Name Witness Signature Date

DOCTOR'S SIGNATURE D A T E

CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

P.LP. & L I A B I L I T Y P O L I C Y

1) THIS OFFICE MUST B E A B L E TO F I L E AND T A K E PRIMARY ASSIGNMENT ON A N Y P.1.P./MED P A Y INSURANCE. Y O U MUST REPORT T H E C L A I M I M M E D I A T E L Y AND F I L E A PIP/MED P A Y APPLICATION TO OPEN T H E CASE.

P.I.P./MED PAY IS FOR THE PAYMENT OF MEDICAL B I L L S , IF IT DOES NOT P A Y WITHIN 60 D A Y S OF D A T E OF SERVICE W E W I L L REQUIRE Y O U TO P A Y AND W I L L ASSIST Y O U IN OBTAINING REIMBURSEMENT. (THERE M A Y B E NONCOVERED, DENIED OR REDUCED CHARGES, THESE A R E YOUR RESPONSIBILITY AS W E A R E UNABLE TO E N T E R INTO A N Y DISPUTE WITH YOUR ATTORNEY OR INSURANCE CARRIER.)

2) WHEN T H E P.I.P./MED P A Y IS E X H A U S T E D OR IN C A S E T H E R E IS NONE, W E MUST B E A B L E TO T A K E ASSIGNMENT ON T H E PATIENT'S CROUP H E A L T H INSURANCE IN ADDITION TO Y O U R ATTORNEY'S LOP.

3) W E W I L L G L A D L Y ACCEPT YOUR ATTORNEY'S SIGNED AGREEMENT L E T T E R AND L E T T E R OF PROTECTION, HOWEVER, IF NO PERSONAL INSURANCE IS A V A I L A B L E , T H E FIRST OFFICE VISIT MUST B E PAID IN F U L L A T TIME OF SERVICE WITH A $100.00 PER MONTH MINIMUM PAYMENT UNTIL PAID IN F U L L OR T H E CASE IS SETTLED. IF T H E R E IS A CHANCE IN ATTORNEYS WE MUST B E NOTIFIED I M M E D I A T E L Y AND A NEW ATTORNEY A G R E E M E N T L E T T E R AND LOP MUST B E REISSUED.

4) ON A L L L I A B I L I T Y CASES, IN ADDITION TO T H E AGREEMENT L E T T E R AND L E T T E R OF PROTECTION, WE MUST B E PROVIDED WITH T H E FOLLOWING INFORMATION: T H E INSURED'S NAME, ADDRESS AND PHONE NUMBER AND THEIR INSURANCE CARRIER'S NAME, ADDRESS, TELEPHONE NUMBER, C L A I M NUMBER AND ADJUSTOR'S NAME.

5) IF Y O U R E C E I V E PAYMENT FROM A N Y INSURANCE COMPANY OR A T T O R N E Y ON T H E CHARGES SUBMITTED B Y THIS OFFICE Y O U MUST BRING SAID PAYMENT TO US WITHIN 48 HOURS.

6) M E D I C A L RECORD COPIES W I L L B E A V A I L A B L E UPON REQUEST AND R E C E I P T OF PAYMENT FOR SAME.

NOTE P L E A S E : THESE OFFICE POLICIES A R E FOR T H E PROTECTION AND B E N E F I T OF A L L . T H E REQUIRED INFORMATION MUST B E BROUGHT TO THIS OFFICE A T T H E TIME OF Y O U R SECOND APPOINTMENT, TO START YOUR C A R E IMMEDIATELY. T H E COURTESY OF WAITING FOR A CARRIER TO P A Y M A Y B E WITHDRAWN IF T H E R E IS NON-COMPLIANCE TO T R E A T M E N T OR OFFICE POLICIES.

1 UNDERSTAND THAT AS T H E PATIENT, 1 A M PERSONALLY AND S O L E L Y L I A B L E FOR A N Y AND A L L OF M Y MEDICAL B I L L S .

PATIENT'S SIGNATURE D A T E

DOCTOR'S SIGNATURE D A T E

C A R O L Y N DA VIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

NON-RESCINDABLE AGREEMENT L E T T E R

This agreement is between and. CAROLYN DAVIS-WILLIAMS, D.C. ~ ADVANCED CHIROPRACTIC CLINIC, P.C. and any third-party involved in the accident on or about

1, , do hereby authorize and agree to pay any outstanding balance due on my account at the time of my release from care.

1 instruct any monies due from my personal injury protection to be paid directly to my physician. Furthermore, claims shall be paid in accordance with Article 5.06-3, in a timely manner, not to exceed 30 days upon receipt of each claim.

1 instruct my attomey to pay in full any outstanding monies due to my physician at the time of settlement with any liability claim that may result from this case. My attomey shall not withhold any portion of the amount due to my doctor under this agreement to offset attorney's fees which my attomey now or hereafrer may claim to be owed by me. 1 instmct my attomey to pay my doctor immediately upon settlement, by way of issuance of a separate draft made payable to the physician/clinic.

1 instmct any third-party individual or insurance carrier that may be liable, to pay my physician direct for any outstanding medical bills which are the result of this accident. I f payment is not made until time of settlement, 1 instmct the third-party to issue a separate draft to be payable to the physician/clinic for the medical bills.

1 understand and acknowledge that all charges incurred by me are my responsibility regardless of any settlement made by a third-party. 1 am instmcting and agreeing to the above conditions as a safeguard to the physicians rights to collect payment. 1 understand that the physician/clinic has the right to expect good faith payments on my account and that full payment is being deferred only until such time as a third-party settlement occurs. I f a settlement does not occur within a reasonable amount of time, 1 agree to make other arrangements to pay my account in full.

Dated: Patient's Printed Name Signature

Dated: Witness's Printed Name Signature

ACKNOWLEDGEMENT OF R E C E I P T OF AGREEMENT

As the insurance adjuster, or attomey, on this claim, 1 acknowledge that 1 have received notice of the patient's Assignment Of Benefits and Non-Rescindable Agreement and will abide as instmcted in such documents.

Date Attomey's or Insurance Adjuster's Signature

DOCTOR'S SIGNATURE D A T E

CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

POWER OF ATTORNEY TO ENDORSE C H E C K S

KNOW A L L MEN B Y THESE PRESENT: That the undersigned has made, constituted and appointed, and by these present does hereby make, constitute and appoint B and any of it's duly authorized agents and employees as and to be the undersigned's name, place and stead to endorse any and all checks or drafts which are made payable to the undersigned alone or to the undersigned and. C A R O L Y N DA VIS-WILLIAMS, D.C. ~ ADVANCED C H I R O P R A C T I C C L I N I C , P.C. which check or drafts are to pay for the health care services which have been performed by C A R O L Y N DA VIS-WILLIAMS, D.C. ~ ADVANCED CHIROPRACTIC C L I N I C , P.C. at the request or with the knowledge of the undersigned and/or the maker of the check or draft.

The undersigned by these presents does thus give and grant unto C A R O L Y N DAVIS-WILLIAMS, D.C. ~ ADVANCED CHIROPRACTIC C L I N I C , P.C. the ftill power and authority to do and perform all and every act and thing whatsoever requisite and necessary to be done in and about the premises as fully as all intents and purposes as the undersigned might or could do to personally present insofar as the endorsing and cashing of said checks are concerned.

The undersigned does hereby ratify and confirm any and all actions taken by the said attomey in accordance with this special power of attomey and which the said attomey shall do or cause to be done by virtue of these presents.

Signed this the day of , 20 .

Patient's Signature Printed Patient's Full Name

IN WITNESS W H E R E O F the undersigned have hereunto set their hands, this the day of ,20 .

Witness's Signature Printed Witness's Full Name

DOCTOR'S SIGNATURE D A T E

CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

HIPAA POLICIES AND PROCEDURES

NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) FOR

TREATMENT. PAYMENT OR HEALTHCARE OPERATONS

I, , understand that as part of my health care, Carolyn Davis-Williams, D.C. - Advanced Chiropractic Clinic, P.C. originates and maintains paper and/or eiectrcnic 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 and surgical information to my bill

A means by which a third-party payer can verify that services billed were actually provided,

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 following rights and privileges:

The right to review the notice prior to signing this consent.

The right to object to the use of my health information for directory purposes, and

The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that, Carolyn Davis-Williams, D.C. - Advanced Chiropractic Clinic, P.C. 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 also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

i further understand that, Carolyn Davis-Wiiiiams, D.C. - Advanced Chiropractic Clinic, P.C. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations.

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

I understand that as part of this organization's treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept / decline the terms of this consent.

Patient's Signature Patient Printed Name Date

DOCTOR'S SIGNATURE D A T E

CAROLYN DA VIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

HIPAA POLICIES AND PROCEDURES

HEALTH CARE AUTHORIZATION FORM

Patient's Name

Patients SS# Date of Birth

THE PATIENT IDENTIFIED ABOVE AUTHORIZES, CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, P.C. TO USE AND OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING:

SPECIFIC AUTHORIZATIONS

• I give permission to CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, P.C. to use my address, phone number and clinical records to contact me with birthday cards, emails, holiday related cards and information about treatment alternatives or other health related information.

OPEN ROOM AUTHORIZATION

• I give CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, P.C. permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with doctor at any time in private; the doctor will provide a room for these conversations.

• By signing this form you are giving CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, P.C. permission to use and disclose your protected health information in accordance with the directives listed above.

EXPIRATION The Authorization shall expire on the following date:

RIGHT TO REVOKE AUTHORIZATION You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, P.C. A clear statement of your intent to revoke this AUTHORIZATION; requires the date of your request, your signature and the revocation is not effective until it is received by the Privacy Official. This AUTHORIZATION is requested by CAROLYN DAVIS-WILLIAMS, D.C. -ADVANCED CHIROPRACTIC CLINIC, P.C. for its own use/disclosure of PHI. You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRAGTIC CLINIC, P.O. will not refuse to provide treatment. You have the right to inspect or copy the PHI to be used/disclosed.

Name of Patient Signature of Patient Date

Name of Guardian if Patient is a Minor Signature of Guardian if Patient is a Minor Date

DOCTOR'S SICNATURF D A T F

CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

HIPAA POLICIES AND PROCEDURES ACKNOWLEDGEMENT OF R E C E I P T OF NOTICE OF PRIVACY P R A C T I C E S

I, , understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. 1 understand that 1 have the following rights and privileges:

• The right to review the notice prior to signing this consent, • The right to object to the use of my health information for directory purposes, and

• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

Patient Printed Name Patient Signature Date

[ ] Consent received by on [ ] Consent added to the patient's medical record on

Attempt was made to obtain written acknowledgement of receipt of out Notice of Privacy Practices, but acknowledgement could not be obtained due to: [ ] Consent refused by patient treatment was rendered. [ ] Consent refused by patient, and treatment refused as permitted. [ ] Communication barrier prohibited the acknowledgment. [ ] Emergency situation prevented obtaining acknowledgment. [ ] Other specify situation

Staff Printed Name Staff Signature Date

DOCTOR'S SIGNATURF D A T F