INTEGRATIVE HEALTH3239 Adams Avenue, San Diego, CA 92116

From the Practitioners and Staff of Adams Avenue Integrative Health

To Our Valued Clients,

At Adams Avenue Integrative Health we are committed to providing the highest qualityholistic healthcare possible to everyone regardless of his or her income level. EveryThursday we gather a group of practitioners who are committed to community serviceand provide free clinics in under-served San Diego communities. The proceeds from ourclinic here at Adams Avenue go to support these free Integrative Health Nights.

Our clinic rates also provide a way for you to afford quality Integrative Healthcare. Asliding scale of fees based on self-reported income is available if you are unable to payour standard rates. No one will ask to see your paycheck; our scale is on the honorsystem. We only ask that you pay what you can afford. And if at any time you would liketo pay more than the recommended fee for services, please feel free to do so --payments above the recommended fee schedule are always greatly appreciated.Additionally, although our rates are all-inclusive (they include gratuity), tips are welcome,but never necessary.

Everything possible has been done to make these services affordable for everyone. Youwill find that in many cases our prices are 2 and 4 times less than other IntegrativeHealth centers. Our goal is that you will feel that the service you receive is worth farmore than what you are paying. If our service falls short of your expectations please letus know immediately.

Please help us to continue in our quest to improve the health and wellbeing of ourcommunity naturally and change the face of healthcare nationally by sharing yourpositive experiences here with others and referring family and friends.

Thank you for your support

Pbone: (619) 546-4806 FAX: (619) 546-5326 Email: info@altbealnet.org

Adams Avenue Integrative Health3239 Adams Avenue

San Diego, CA 92116619-546-4806 - Phone619-546-5326 - Faxwww.althealnet.orgINTEGRATIVE HEALTH

T his is a CONFIDENTIAL questionnaire to determine the most appropriate treatment plan for you.

Name ---------------------------------------------------------------------- Date ---------------------Home Address -----------------------------------------------------------------

Ci~ _

State ----- Zip _ Primary Phone______________________Secondary Phone _

Email address: -----------------------------------------------------------------------------------------------------------------------Occupation _ Person responsible for your account _

Emergency Contact _ Phone ------------------------------Who can we thank for referring you? _

Sex: M F Height: Weight: Birth Date. _

Marital Status: D Married D Single D Divorced DWidowed D Other # of Children: _

(Check all that apply)

DYes 0 No When With Whom? ---------------------------------DYes DNo When With Whom? ------------COMPREHENSIVE NATUROPATIDCEVALUATIONCOMPREHENSIVE CHIROPRACTIC EVALUATIONCOMPREHENSIVE ACUPUNCTURE EVALUATIONMASSAGETHERAPY EVALUATION& TREATMENTENERGETIC HEALINGAND TOUCH THERAPYCOMPREHENSIVE NUTRITIONAL EVALUATION

Previous Acupuncture?Previous Chiropractic?

I am interested in a:

I understand that the majority of the work done at Adams Avenue Integrative Health is considered WellnessCare and is therefore not covered under most insurance policies. I further understand that the doctors andother practitioners at Adams Avenue Integrative Health are not listed as providers for any insurance carriers;including Medicare and therefore cannot file claims to the insurance providers. However, itemized statementsor "Superbills" are available upon request.

InitIalS.

Allpayment for services rendered is due at the time of service, unless previous arrangements have been made.

Patient (Guarantor) Date: _Signature

What are your top three complaints you wish to be addressed during the course of your treatments atAdams Avenue Integrative Health? Please describe the ways in which your life has beeneffected/restricted because of these health concerns.1. _

2. ~ _

3. _

Past Medical History: List any accidents, surgeries, (including cosmetic surgery) or hospitalizations you'vehad (Include dates):

Please list any allergies, dietary restrictions (Vegetarian, Vegan, Raw, etc.), food sensitivities or cravingsthat you have:

Please indicate any illnesses you or a blood relative (parent, grandparent, or sibling) have had:ILLNESS You Relative Who? ILLNESS You Relative Who?Cancer 0 0 Diabetes 0 DHepatitis D 0 Heart Disease 0 0High Blood Pressure 0 0 Seizures 0 0Rheumatic Fever 0 0 Emotional Dis. D 0Infectious Diseases D 0 Tuberculosis D DSexually Transmitted Diseases: DGonnorhea 0Syphilis 0HIV DHPV DChlamydia 0Herpes

Please indicate the use and frequency of the followingCoffee/ Black Tea TobaccoRecreational Drugs Alcohol

Daily Water Intake: _Soda Pop

List any medications and supplements you are currently taking: (continue on back if needed)Medicine Dosage Reason How Long Prescribed By Last checkup

(n::ttp)

(J oFor Women

• j'..:

Are you pregnant? 0 Yes 0 No # of pregnancies _# of live births # of Abortions____ # of Miscarriages _Date of last: Gynecologic exam_______ Pap Smear _Mammogram Bone Density Scan _Results _

Age of 1st period (menarche) _Age of last period (menopause) _Number of days between periods _Numberofdaysofflow _Color of flow _

Clots? 0 Yes 0 No Color __ ==~Average number of pads you use per day: 1st day 2nd day 3rd day __ 4th day __ + days _Have you been diagnosed with: 0 Fibroids 0 Fibrocystic Breasts a Endometriosis a Ovarian Cysts 0 PID Other _Location of Pain: 0 Lower abdomen 0 Lower back a Thighs a Other _Nature of Pain (Pleaseindicatebefore,duringor aftermenses) Other Symptoms related to mensesCramping Stabbing 0 Discharge 0 Vaginal drynessBurning Aching 0 Nausea 0 ConstipationDull Bloating 0 Swollen breasts 0 Mood swingsConsistent Intermittent 0 Poor appetite 0 Hot flashesBearing down sensation 0 Increased libido 0 Decreased libido

o Headacheo Diarrheao Ravenous appetiteo Night sweatso Insomnia

For Men

Date of last prostate check up _Labresults _

Frequency of Urination: daytime nighttime _Symptoms related to prostateo prostate problems 0 Delayed streama Rectal dysfunction 0 Increased libidoo Back pain 0 Groin pain

PSAresults _ Manual prostate exam results _

Color of urine: 0 clear 0 murky

o Dribblingo Decreased libidoo Testicular pain

odor: _

o Incontinenceo Premature ejaculationother _

o Retention of Urineo Impotence

Svmptom Survey (For Everyone)

The following is a list of symptoms that you mayor may not ever experience. Please indicate as follows:no mark ( ) = never experience check mark (0,1 ) = sometimes experience

__ lack of appetite __ abdominal pain __ eye problems__ excessive appetite __ chest pain __ jaundice (yellowish__ loose stool or diarrhea __ sciatic pain eyes or skin)__ digestive problems, __ headaches __ difficulty digesting

indigestion __ pain or coldness in the oily foods__ vomiting genital area ~all stones__ belching, burping __ light colored stool__ heartburn/reflux __ cough __ soft or brittle nails__ feeling the retention of __ shortness of breath __ easily angered or

food in the stomach __ decreased sense of agitated__ tendency to become smell __ difficulty in making

obsessive in work, __ nasal problems plans or decisionsrelationships... __ skin problems __ spasms or twitching

of muscles__ feeling of

claustrophobia__ bronchitis__ colitis or

diverticulitis

__ insomnia, difficultysleeping

__ heart palpitations__ cold hands and feet__ nightmares__ mentally restless__ laughing for no

apparent reason__ angina pains

__ low back pain__ knee problems__ hearing impairment__ ear ringing__ kidney stones__ decreased sex drive__ hair loss__ urinary problems

__ constipation__ hemorrhoids__ recent use of antibiotics

plus sign (+) = frequently experience__ fatigue__ edema__ blood in stool__ black tarry stool__ easily bruised__ difficult to stop bleeding__ asthma__ tendency to catch

colds easily__ intolerance to

weather changes__ allergies__ hay fever__ dizziness__ tendency to faint easily__ high cholesterol levels__ sudden weight loss

Adams Avenue Integrative HealthPOLICIES and RESPONSIBILITIES AGREEMENT

PLEASE READ CAREFULLY AND INITIAL EACH ITEM BELOW.

Cancellations and Rescheduling1 Part of our mission is to make Integrative Healthcare available and affordable to everyone. We value your time

and hold your appointment time specifically for you. If for any reason you need to cancel or reschedule anappointment, we require 24 hours notice or you may be charged a cancellation fee for each scheduledservice, payable prior to your next appointment. If treatments have been purchased in a package, the missedappointment may be deducted from the number remaining. We understand that situations arise and you mustcancel or reschedule with less than a 24 hour notice. If you call to explain the situation, we may allow you aone time "free pass" for last minute-cancellation. This will be at the discretion of the practitioner.

I have read and understood the Cancellation and Rescheduling PolicyInitials

Privacy and Confidentiality

2 Your confidentiality is important to us. None of your personal information is shared or disclosed outside of ourclinical team without your express written permission.

3 Since several people are being treated in the same room at once, it is vital that we work together to respectyour privacy and the privacy of others. Your intake will be done in a soft voice and there will be ambient musicin the background to drown out the discussion of any sensitive issues. Let us know if there are certain topicsthat need extra discretion and/or if you prefer to do your intake in a more private setting.

4 If you happen to overhear someone else's private information, do not share this information with others. Weask that you show the same respect for others as you would expect for yourself.

I have read and understood the Privacy and Confidentiality PolicyInitials

Insurance and Financial Responsibility

5 We are a community based Integrative Health Center operating under a 501 (c) (3) Nonprofit. Our goal is tomake the highest quality natural healthcare readily available at the most affordable prices. Unfortunately,insurance companies will not accept "Sliding Scale" fee structures. For this reason, we are unable to acceptinsurance. None of our practitioners are listed as providers for any insurance providers or third party payors,including Medicare or Medi-Cal and therefore cannot file claims to the insurance providers. We are able toprovide you with a detailed list of services called a "Superbill." Many carriers now allow you to submit Superbillsfor reimbursement. You will need to check with your insurance company in advance to see if they accept"Superbills". You will be expected to pay the full amount due at the time of your treatment. Then you cansubmit the "Superbills" for reimbursement from your provider, if they accept them.

6 All services, nutritional and herbal products, orthotics and other items are non-refundable.7 Fees for all services, nutritional and herbal products, orthotics and other items are due and payable at the time

items are received and/or services are rendered.8 Fees will be assessed on checks returned for any reason at the maximum amount allowed by the State.9 By signing this agreement you agree to accept full financial responsible for any and all Charges incurred at

Adams Avenue Integrative Health.10 Please understand that we cannot guarantee any level of success of treatment administered, nor is the result

or outcome of treatment related to your obligation to pay for same.

I have read and understood the Insurance and Financial Responsibility PolicyInitials

I have read, or have had read to me, the above terms of Policies and Responsibilities Agreement. I have had theopportunity to have any questions answered to my satisfaction. I agree to and accept fully these terms ofagreement.

Patient (Guarantor) Signature Date: _