Name. Date of Birth Age Occupation. Chief Complaint Please describe your present complaint(s)

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1 Health History E Springfield Ave Suite 100 Spokane Valley, WA Date / / Name Date of Birth Age Occupation Are you here because of: AUTO ACCIDENT? Y / N WORK INJURY? Y / N Chief Complaint Please describe your present complaint(s) When did it begin? The onset was: Sudden Gradual Has this occurred before? Yes No If yes, when? Is your problem: Getting Worse Getting Better Staying the Same Have you had chiropractic care in the past? Yes No If yes, with whom? Approx. Date of Last Visit Primary Care Physician Approx. Date of Last Visit Have you seen your medical doctor for this condition? Yes No What, if any other treatments have you tried for this condition? Does anything help decrease your symptoms? Check any of these activities that increase you pain: Bending Standing Sitting Lying Down Lifting Walking Coughing Straining with bowel movement Driving in Car Rising from a seated position Lifestyle Restrictions Are you more irritable due to this condition? Yes No Have you missed any work due to this condition? Yes No If yes, how long? Does the pain interfere with your sleep? Yes No Are you unable to perform any of these activities: Yardwork Recreation Cleaning the House Other Past Health History Major Surgeries? Yes No Describe Previous Auto Accidents or Injuries Any Hospitalizations in the past 5 years? Have you ever been diagnosed with any of the following: High Blood Pressure Yes No Diabetes Yes No Stroke, TIA, Heart Disease Yes No Cancer Yes No Are you a smoker? Yes No Former smoker? Yes No Any other health problem not listed? Are you currently taking any medications? Yes No Pain Medication Muscle Relaxants Ibuprofen/Tylenol Blood Pressure Medication Blood Thinners Please complete the back of this form

2 Please draw the location of your pain or discomfort on the images below. Use the symbols shown to represent the type(s) of pain: D=Dull B=Burning N=Numb S=Sharp/Stabbing T=Tingling C=Cramping Please rate your current level of pain by circling a number: No Pain Low Moderate Intense Emergency Using this scale, over the last 30 days the pain has been: At Worst At Best On Average Wolf Chiropractic Clinic E. Springfield Avenue Suite 100 Spokane Valley, WA

3 Patient Privacy Summary Expires January 1, 2013 Date We are committed to preserving the privacy of your personal health information. In fact, we are required by law to protect the privacy of your medical information and to provide you with the notice describing: HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. We are required by law to have your written consent before we use or disclose to others your medical information for purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you, and the related administrative activities supporting your treatment. We may be required or permitted by certain laws to use and disclose you medical information for other purposes without your consent or authorization. As or patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting the information, obtaining an accounting of our disclosures of your medical information, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated. We have available detailed Notice of Privacy Policies which fully explains your rights and our obligations under law. We may revise our Notice from time to time. You have the right to receive a copy of the most current Notice in effect. The effective date at the top left hand side of this page indicates our most current Notice in effect. If you have not yet received a copy of our current Notice, please ask the front desk, and we will provide you with a copy. Signed Date Printed Name Relationship to Patient New regulations and the law require that we have your consent to send you the following items from our office: Newsletters, Gifts, Recall Cards, s, Special Offers, Personal Greetings YES, you have my permission to send the above listed items to me. NO, do not send me any of these items. Signed Date

4 Informed Consent Before beginning treatment, it is our office policy to inform you of what to expect, possible complications of chiropractic, as well as other forms of treatment. Remember that all forms of treatment (including nontreatment) have associated risks. If you have any questions, please ask the doctor. WHAT TO EXPECT The treatment in our office will consist of manipulation of the joints and soft tissues (muscles and ligaments), using the doctor s hands and/or a mechanical instrument. You may feel movement, and you may hear joint clicks or other noises. Physical therapy methods, including therapeutic exercise, massage and heat or ice may also be used. CHIROPRACTIC RISKS Chiropractic treatment is one of the safest methods of treating spinal problems. Still, unexpected problems can occur. Minor, temporary problems such as soreness and stiffness can occur, especially at the start of treatment. More significant problems, such as fracture of a weakened bone or sprain/disc injuries are rare. A stroke following neck manipulation is an extremely rare complication, occurring less than 1 per million treatments. Stroke has also been the result of ordinary activities, such as head turning and sneezing. OTHER TREATMENTS AND RISKS There are other forms of treatment used by medical doctors. Their risks include: Medications: Many commonly used medications such as NSAIDs (Advil, Aleve, Ibuprofen) carry risks of tissue damage, including stomach ulcers or kidney damage. This damage can occur quickly and may be irreversible. There are significantly higher risks of developing serious complication with NSAIDs compared with chiropractic. The annual number of hospitalizations for serious GI complications related to NSAIDs is estimated to be at least 103,000. Conservative estimates of NSAID-related deaths in the US is 16,500 per year. New England J Med 1999 Other medications are habit forming, and may mask pain to allow further injury or tissue damage. Surgery: Surgery is the treatment of choice in less than 1% of back pain patients. Your doctor will and continue to screen you for surgical indicators and will refer you for a surgical opinion if necessary. Clinical results of surgery for simple, mechanical lower back pain have been disappointing and may expose you to unnecessary hospital and medication risks. Rest/ Non-Treatment: Bed-rest has been shown to increase the likelihood of recurrence of back pain episodes, and make chronic pain more likely. Likewise, non-treatment may cause a permanent mechanical problem to develop, causing future back problems. I have read and understand the above and give my consent to begin chiropractic treatment. Printed Name Date Signature Wolf Chiropractic Clinic E Springfield Avenue Spokane Valley, WA 99037

5 MOTOR VEHICLE INSURANCE INFORMATION Patient Name: Date of Accident: Name of Insured: 1. Your Automobile Insurance Company: Billing Address: Policy Number: Claim Number: UIM Coverage: Yes No Claim Number: PIP Coverage: Yes No Agent: Phone: Fax: Claims Adjuster: Phone: Fax: Verified by: Date: 2. Other Automobile Insurance Company: Billing Address: Has Clear Liability Been Established? Name of Responsible Party: Address of Responsible Party: Claim Number: Claims Adjuster: Verified by: Date: Phone: Fax: 3. Do you have legal representation? Yes No If yes, with whom? Name: Phone: Fax: Address: Case Coordinator: Verified by: Date:

6 Patient Name Date Date of Injury/Accident Approximate Location of Auto Accident Type of Collision: Rear Impact Head On Single Car Roll-Over Side Impact involving what part of your vehicle? passenger side driver s side front Did your car hit anything else after it was hit? Yes No If yes, please describe: Please describe to the best of your knowledge what happened at the time of the accident: What type of vehicle were you in? Year Make Model Where were you seated in the vehicle? Driver Front Seat Passenger Rear Seat Passenger on the: driver s side passenger side Were you wearing a seat belt? Lap belt and shoulder harness Lap belt Only None What direction were you facing at time of impact? Describe the other vehicle: Year Make Model Is your vehicle equipped with airbags? Yes No Did the airbag(s) deploy? Yes No Were you: Aware of the impending collision Caught by surprise Did you brace for the impact? Did you strike anything within the vehicle? If yes, did you have any cuts or visible bruising? Road Conditions: Dry Wet Ice Snow Compact Snow/Ice Other Time of Day: Daylight Dawn Dusk Dark At the time of the accident, your vehicle was: Stopped Slowing Accelerating Steady Rate of Speed At the time of the accident, the other vehicle was: Stopped Slowing Accelerating Steady Rate of Speed Was your car drivable or towed from the scene? Was the other car drivable or towed from the scene? Were the police or State Patrol notified? Was anyone cited? AFTER THE ACCIDENT: Where did you go after the accident? Mode of Transportation: you were able to drive yourself transported by another individual transported by ambulance Who was the first doctor you saw after the accident? Date: His/Her Office ER Urgent Care Emergency Department or Urgent Care: Yes No Date: Time: X-rays, CT scans or MRI? Yes No If yes, what body parts were imaged? Medication prescribed? Yes No Other instructions/treatment rendered: Ice Heat Follow-up with MD Other Completed by Date

7 Patient Information - Please Print Clearly Address Patient Name Date of Birth Age Street & Mailing Address City State Zip Home Phone Cell Phone Sex: Male Female Married Single Widow(er) Divorced Social Security # Current Employer Department Work Phone Ok to call at work? Y / N Spouse, Partner or Guardian Birth Date Address (if different) Employer Work Phone Emergency Contact (person not living with patient) Relationship to Patient Phone Is this visit because you have you been injured in an accident? Yes No Date of Injury? If yes, was the accident work related? Yes No Was the injury an auto accident? Yes No Have you hired an attorney because of your injury? Yes No If yes: Attorney s Name Phone If Work-Related: Employer at time of Injury Phone Claim # Other Insurance? Please Read Carefully: Our office bills most insurance carriers. All co-pay and deductible amounts are expected to be paid at the time of your appointment unless other arrangements have been made in advance. Should you have a balance for any reason after your insurance has processed our bill, a statement will be sent to you. It will be your financial responsibility to pay this balance due. Medicare patients please note that examinations and massage therapy performed in this office are not covered by Medicare and most secondary insurances. Patient Initials I understand that if my insurance company requires a referral, it is my responsibility to obtain this referral from my medical doctor. I also understand that is my responsibility to fully understand my own insurance benefits and that the benefits quoted to me by this office are based on information provided to Wolf Chiropractic Clinic by my insurance carrier. I accept the full responsibility of keeping track of the number of visits allowed and the number of visits used, regardless of where those services have been performed. The information provided to me by this clinic does not guarantee benefits or coverage for services provided by this office. Patient Initials I have read and understand that if my insurance does not pay in full for the services provided by the health care providers in this clinic, I assume liability for the allowed unpaid portion. I authorize the release of any medical records that might be necessary to facilitate payment of services and authorize the insurance company to make payments direct to the doctors. It is understood that the doctors within this office have access to each other s records without further authorization, and that my records may be released to other physicians directly involved in my care. Patient Initials I understand that keeping appointments or canceling them with adequate notice prior to my appointment time is my responsibility. Otherwise, I may be charged a regular office visit fee for missed appointments ( no shows ). Date Patient or Guardian Signature

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