STULL CHIROPRACTIC CENTER 2224 Woodman Drive, Kettering, OH 45420

(937) 259-8850 (p) (937) 259-8224 (f)

Please print clearly and complete all applicable items.

Date: ___________________________________________ Patient # _________________________________________

First Name: __________________________________ M.I. _____________ Last: _______________________________

Address: ______________________________________ City: _______________________ State: _______ Zip: _______

Birth Date: _____/______/________Sex: M F SS# ____________________ Work #: _________________________

# of Children: _____________ Home #: ______________________ Cell #: ________________ Work #: _____________

Email Address: _____________________________________ Occupation: _____________________________________

Employer: ________________________________ Employer’s Full Address: ___________________________________

Who referred you to our office? ______________________________ Family Doctor: ___________________________

INSURANCE INFORMATION

Primary Insurance Company: _____________________________________ Secondary: __________________________

Subscriber’s Name (if you are a dependent): _______________________________ Relationship: __________________

Subscriber’s Date of Birth: ______________________________

MEDICAL INFORMATION Purpose of today’s visit/major complaint? _______________________________________________________________

Date symptoms appeared: _________________________ Have you ever had the same or similar condition? YES NO

Dates of serious illnesses: ____________________________________________________________________________

What surgeries have you had (dates): ___________________________________________________________________

Do you smoke? _____ Y _____N In the past? _____Y ______ N How many per day? ________ Since When? _______

List of supplements or medications you take: ____________________________________________________________

Circle the severity (0 = No Pain to 10 = Very Severe Pain) and Frequency of Pain (of the week you experience the pain).

Condition / Problem Severity Minimal Severe

Frequency (of week)Constant

a. ____________________________b. ____________________________c. ____________________________d. ____________________________e. ____________________________

1. Please mark the figures where you experience pain

2. Symptoms are worse in the (check what applies)

Morning Increase during the day

Afternoon Same all day

Night Decrease during the day

Burning Aching Throbbing Numbness Tingling Pins & Needles3. Symptom (a) is: Sharp Dull 4. Symptom (b) is: Sharp Dull Burning Aching Throbbing Numbness Tingling Pins & Needles

Occasional

5. Is this condition interfering with _______ Work _______ Sleep _______ Daily Routine _______ Recreation

6. Any other Musculoskeletal problems? ______ No _______ Yes Neurological problems? _______ No ______ Yes

CONDITIONS YOU HAVE OR HAVE HAD: Please check all that apply

AIDS/HIV Depression High Blood Pressure Prostate Problem Alcoholism Diabetes High Cholesterol Prosthesis Allergies Digestive Disorders Hypoglycemia Rheumatic Fever Anemia Dizziness Neck Pain Sinus Troubles Anorexia Epilepsy Nervousness Stroke Arthritis/Joint Pain Fatigue Neuritis Tuberculosis Asthma Gout Numbness Ulcer Backaches Headaches Osteoporosis Urinary Trouble Bleeding Disorders Heart Trouble Pacemaker Venereal Disease Breathing Problems Hepatitis Parasites Weight Loss Bulimia Cancer

Hernia Herniated Disc

Pinched Nerve Poor Circulation

Yeast/Candida

Check each box that applies or enter age

LIVI

NG

OTHER DISEASES, ABNORMALITIES, COMPLICATIONS?PLEASE DESCRIBE

FATHER

FATHER’S Family

MOTHER

MOTHER’S FAMILY

YOUR SIBLINGS

BROTHER/SISTER

BROTHER/SISTER

YOUR CHILDREN

SON/DAUGHTER

SON/DAUGHTER

MANDATORY FOR PATIENTS WITH MEDICARE Date of last X-ray? _____________________________________

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize

the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs for chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fee for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of you Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk, before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office.

PATIENT’S SIGNATURE ____________________________________________________ DATE: ____________________

GUARDIAN’S SIGNATURE AUTHORIZING CARE _________________________________ DATE: ____________________

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STULL CHIROPRACTIC CENTER 2224 Woodman Drive, Kettering, OH 45420

(937) 259-8850 (p) (937) 259-8224 (f) Patient Name: _____________________________________________ Date: ___________________________

Terms of Acceptance The goal of our office is to enable patients to gain control of their health. To attain this we believe communication is

the key. There are often topics that are hard to understand, and we hope this document will clarify those issues for you.

Please read the below and if you have any questions, please feel free to ask one of our staff members.

Informed Consent:

A patient, in coming to the chiropractic doctor, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects,

deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or care if he/she is aware that such care may be contra-indicated. Again, it is the responsibility of the

patient to make it known, or to learn through healthcare procedures what he/she is suffering from: latent pathological defect5s, illnesses or deformities which would otherwise not come to the attention of the chiropractic

physician. The chiropractic doctor provides a specialized, non-duplicating health care service. Your Doctor of Chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand that if I am accepted as a patient by a physician at Stull Chiropractic, I am authorizing them to

proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request.

WOMEN ONLY:

To the best of my knowledge I am / am NOT pregnant and (give my permission / don’t give permission) to X-ray me for diagnostic interpretation. (circle one above) (circle one above)

Missed Appointments

There is a possible fee charged for all appointments that are not canceled prior to scheduled visit. Any massage appointment that is not canceled 24 hours prior to scheduled appointment will be charged $35 - $70

Consent to Evaluate and Treat a Minor

I, _______________________________ being the parent or legal guardian of ________________________, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.

Communications

In the event that, we would need to communicate your healthcare information, to whom may we do so? Spouse: __________________________________________ Children: _________________________________________ Others: __________________________________________ No One: ___________

May we leave messages regarding your personal healthcare information on any answering device, i.e. home answering machines or voicemails? Yes ____ No _____

Acknowledgement

I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have

been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy.

Print Name: ______________________________________________________________

Signature: ____________________________________________________________ Date: ___________________