NEW PATIENT HEALTH HISTORY

Patient’s Full Name _____________________________________________________________ Sex ❏ F ❏ M Date _______/_______/_______

Patient’s Social Security # _________________________________________________ Date of Birth _______/_______/________ Age ____________

E-mail _________________________________________________________________________________________________________________________

Parent or Guardian’s Name (if patient under age 18) _____________________________________________________________________________

Address _________________________________________________________________________________ Apt. (if applicable) __________________

City ______________________________________________________________________ State _____________________ Zip ______________________

Home Phone (________)____________________ Work Phone (________)____________________ Cell Phone (________)_____________________

Emergency Contact ______________________________________________________ Emergency Contact Phone (________)___________________

Patient’s Occupation _____________________________________________________ Employer _____________________________________________

Patient’s Marital Status ❏ Single ❏ Married ❏ Divorced ❏ Widowed If Married, Spouse’s Name _______________________________

Number of Children _______ Spouse’s Occupation ___________________________ Spouse’s Employer ___________________________________

Name of Referring Physician, Patient, or Family Member (if applicable) _____________________________________________________________

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Patient Contact Information

Two options for completing this form:

• Please fill out on your computer, print it, and bring it to your first appointment.

• Please print out this form, then fill it out using a pen, and bring it to your first appointment.

Note: Regardless of the completion method selected above, the diagrams on page four and signatures on pagesthree, five, and six require you to use a pen to complete them. If you email us the form, this can be done in our office.

Insurance Coverage Information

Do You Have Health Insurance Coverage? ❏ Yes ❏ No* If yes, please present your health insurance ID card when you arrive at ouroffice for your first visit. We will make a photocopy of it for our files.

If insured, are you the primary name on the policy or is your spouse? ❏ I am the primary name ❏ My spouse is the primary name

If Spouse, Spouse’s Name __________________________________________________________________________ DOB _______/_______/_______

Are You Enrolled in ❏ Medicare ❏ Medicaid ? If you have Medicare supplemental insurance, please present your health insuranceID card when you arrive at the our of fice for your first visit. We will make a photocopy of it for our files.

Are you suffering from an auto accident injury that resulted in a claim? ❏ Yes ❏ No If yes, please bring the auto accident claiminformation received from your insurance agent. We will make a photocopy of it for our files.

* If you do not have health insurance coverage, Advanced Family Chiropractic Center offers convenient payment plans that fit most budgets.

Reasons for Seeking Care

Chief Complaint (include location) ______________________________________________________________________________________________

Rate Intensity (0 = No Pain/Symptoms, 10 = W orst Possible Pain/Symptoms) ❏ 0 ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5 ❏ 6 ❏ 7 ❏ 8 ❏ 9 ❏10

Secondary Complaint, if any (include location) ___________________________________________________________________________________

Rate Intensity (0 = No Pain/Symptoms, 10 = W orst Possible Pain/Symptoms) ❏ 0 ❏ 1 ❏ 2 ❏ 3 ❏ 4 ❏ 5 ❏ 6 ❏ 7 ❏ 8 ❏ 9 ❏10

Have You Ever Received Chiropractic Care? ❏ Yes ❏ No If Yes, When? ________________________________________________________

Nature of Injury ❏ Automobile ❏ Work ❏ Other ____________________________________________________________________________

Complaint(s) Began When & How? _____________________________________________________________________________________________

Reasons for Seeking Care (continued)

Description of the Complaint/Pain: Dull Aching Sharp Shooting Burning Throbbing Deep Nagging

Other Describe ____________________________________________________________________________________________________________

Does This Pain Radiate or Travel (Shoot) to Any Other Areas of Your Body? Yes No If Yes, Where? ___________________________

Do You Have Any Numbness or Tingling in Your Body? Yes No If Yes, Where? ______________________________________________

How Frequent Is Complaint Present, How Long Does It Last?_______________________________________________________________________

Does Anything Aggravate the Pain? _____________________________________________________________________________________________

Does Anything Make the Pain Better? ___________________________________________________________________________________________

Medical History

Your Height: __________feet __________inches Your Weight: __________pounds

Previous Care for Your Complaint/Pain (Treatments, Medications, or Surgery You’ve Sought for Your Complaint) _______________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

Have You Been Treated for Any Conditions in the Last Year? Yes No If Yes, What? __________________________________________

________________________________________________________________________________________________________________________________

Approximate Date of Last Physical Exam_______/_______/_______ Females: Could Y ou Be Pregnant? Yes No Not Sure

Have You Had X-Rays Taken in the Past Three Years? Yes No If Yes, Where? ________________________________________________

What Medications Are You Taking and for What Conditions (Please List Dosage and Amounts, etc.) __________________________________

________________________________________________________________________________________________________________________________

What Vitamins, Minerals, or Herbs Do You Currently Take? (Please List Dosage and Amounts, and for What Condition, etc.) ____________

________________________________________________________________________________________________________________________________

Family Member (Mother, Father, etc.) Present and Past Health Conditions (Heart Disease, Cancer, Diabetes, Arthritis, etc.)

1. _____________________________________________________________________________________________________________________________

2. _____________________________________________________________________________________________________________________________

3. _____________________________________________________________________________________________________________________________

Have You Ever: If Yes, Briefly Explain:

Broken Bones Yes

Been Hospitalized Yes

Been in an Auto Accident Yes

Had Sprains/Strains Yes No ___________________________ _______________________

No ___________________________ _______________________

No ___________________________ _______________________

No ___________________________ _______________________

Had a Sports Injury Yes No ___________________________

No ___________________________

No ___________________________

Been Struck Unconscious Yes

Had Surgery Yes

Used a Cane or Walker Yes No ___________________________

_______________________________

_______________________________

_______________________________

_______________________________

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______________________________________________________

______________________________________________________

______________________________________________________

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Medical History (continued)

Have You Ever Suffered from:

❏ Alcoholism ❏ Allergies ❏ Anemia ❏ Arteriosclerosis ❏ Arthritis ❏ Asthma

❏ Back Pain ❏ Breast Lump ❏ Bronchitis ❏ Bruise Easliy ❏ Cancer ❏ Chest Pain

❏ Cold Extremities ❏ Constipation ❏ Cramps ❏ Depression ❏ Diabetes ❏ Digestion Problems

❏ Dizziness ❏ Ears Ring ❏ Eye Pain/Problems ❏ Fatigue ❏ Frequent Urination ❏ Headaches

❏ Hemorrhoid ❏ High Blood Pressure ❏ Hot Flashes ❏ Irregular Heart Beat ❏ Irregular Cycles ❏ Kidney Infection

❏ Kidney Stones ❏ Loss of Memory ❏ Loss of Balance ❏ Loss of Smell ❏ Loss of Taste ❏ Neck Pain/Stiffness

❏ Nervousness ❏ Nosebleeds ❏ Pacemaker ❏ Polio ❏ Poor Posture ❏ Prostate Trouble

❏ Sciatica ❏ Short Breath ❏ Sinus Infection ❏ Sleep Disorder ❏ Spinal Curvature ❏ Stroke

❏ Swollen Ankles ❏ Swollen Joints ❏ Thyroid Condition ❏ Tuberculosis ❏ Ulcers ❏ Varicose Veins

❏ Venereal Disease ❏ Other ___________________________________________________________________________________________________

Lifestyle and Habits

Job Description (desk job, physical lifting, on feet, etc.) ___________________________________________________________________________

Work Schedule (Full-time, Part-time, Hours, Shift) _________________________________________________________________________________

Recreational Activities (type and frequency) ______________________________ _______________________________________________________

Habits None Light Moderate Heavy

Alcohol ❏ ❏ ❏ ❏

Coffee ❏ ❏ ❏ ❏

Tobacco ❏ ❏ ❏ ❏

Drugs ❏ ❏ ❏ ❏

Exercise ❏ ❏ ❏ ❏

Sleep ❏ ❏ ❏ ❏

Appetite ❏ ❏ ❏ ❏

Soft Drinks ❏ ❏ ❏ ❏

Water ❏ ❏ ❏ ❏

Salty Foods ❏ ❏ ❏ ❏

Sugary Foods ❏ ❏ ❏ ❏

Artificial Sweetners ❏ ❏ ❏ ❏

Do You Experience Pain Everyday? ❏ Yes ❏ No

Do Symptoms Interfere with Life? ❏ Yes ❏ No

Does Pain Wake You at Night? ❏ Yes ❏ No

Symptoms Worse at Certain Times? ❏ Yes ❏ No

Does Weather Affect Your Symptoms? ❏ Yes ❏ No

Do You Wear Orthotics? ❏ Yes ❏ No

Do You Take Vitamin Supplements? ❏ Yes ❏ No

Do You Typically Sleep 7-8 Hours/Day ❏ Yes ❏ No

Disclaimer:

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this of fice

of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes.

I authorize the release of any medical information necessary to process this claim and request payment of insurance benefits to be

paid directly to Dr. John R. Owings or Advanced Family Chiropractic Center P.C. However, in the event that the insurance company

does not pay for services provided by the doctor , I understand that all billable services will be transferred to me, the patient, for pay-

ment and I am responsible for payment of those services. Insurance co-pays and deductibles are due at time of service.

Patient’s Signature ______________________________________________________________ Date ________________________________________

(If under 18, parent or guardian’s signature)

Average Level of Stress in Your Life

❏ No Stress ❏ Very Little Stress ❏ Some Occasional Stress ❏ Moderate Stress ❏ Significant Stess ❏ High Stress ❏ Severe Stress

Name _________________________________________________________________________ Sex ❏ F ❏ M Date _______/_______/_______

Using the Letters Below, Mark the Areas of the Diagram to Indicate Where You Feel the Following Sensations:

A = Aches B = Burning N = Numbness P = Pins & Needles S = Stabbing O = Other

Indicate the Severity of Your Symptoms by Marking an “X” within the Range Below:

How bad are your symptoms now? _______________________________________________________________________________________

How bad have they been in the past? ________________________________________________________________________________________

• Please print this page and then use a pen to complete the information requested below.

no symptoms/pain most severe symptoms/pain

no symptoms/pain

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most severe symptoms/pain

Chiropractic Diagram

Nutritec Software Symptom Survey

NAME: _____________________ DATE: ___________

Phone: ____________________ E-mail: ___________

Fax: __________________ DOB: ____/____/____

Sex: Male Female Tissue Calcium:_______

Height : ______________ Weight : _____________

Blood Pressure: Pulse:____Sitting:________ Laying:_______ Standing:________

INSTRTIONS: Completely black out one of the three circles: 1-mild, 2-moderate, 3-severe MILD symptoms (once or twice last 6 months) MODERATE symptoms (once or twice last month) SEVERE symptoms (Chronic, once or twice last week) Leave circles BLANK if they do not apply to you!

1 2 3 ----------- GROUP 1 ---------- 1 Acid foods upset 2 Feel chilled often 3 “Lump” in throat 4 Dry mouth-eyes-nose 5 Pulse speeds after meals 6 Keyed up; unable to feel calm 7 Cuts heal slowly 8 Gag easily 9 Unable to relax; startles easily 10 Extremities cold and/or clammy 11 Strong light irritates 12 Urine amount reduced 13 Heart pounds after retiring 14 “Nervous” stomach 15 Appetite reduced 16 Cold sweats often 17 Body temperature rises easily 18 Skin sensitive to touch 19 Staring, blinks little 20 Frequently has a sour stomach ----------- GROUP 2 ---------- 21 Joint stiffness after rising 22 Muscle-leg-toe cramps at night 23 “Butterfly” stomach, cramps 24 Eyes or nose watery 25 Eyes blink often 26 Eyelids swollen or puffy 27 Indigestion soon after meals 28 Always seems hungry; “lightheaded” often 29 Food digests rapidly 30 Vomit frequently 31 Frequently hoarse 32 Irregular breathing 33 Pulse slow or feels “irregular” 34 Slow gag reflex 35 Difficulty swallowing 36 Alternating constipation and diarrhea 37 “Slow starter” 38 Not easily chilled 39 Perspire easily 40 Poor circulation or sensitive to cold 41 Subject to colds, asthma, bronchitis ----------- GROUP 3 ---------- 42 Eat when nervous 43 Excessive appetitie

1 2 3 ----------- GROUP 3 continued ---------- 44 Hungry between meals 45 Irritable before meals 46 Get “shaky” if hungry 47 Feeling fatigued, eating relieves 48 “Lightheaded” if meals delayed 49 Heart palpitates if meals missed or delayed 50 Afternoon headaches 51 Upset feeling from excessive eating of sweets 52 Awaken after few hours sleep hard to get back to sleep 53 Crave candy or coffee in afternoons 54 Moods of depression “blues” or melancholy 55 Abnormal craving for sweets or snacks ----------- GROUP 4 ---------- 56 Hands and feet go to sleep easily, numbness 57 Sigh frequently, “air hunger” 58 Aware of “breathing heavily” 59 Discomfort at high altitude 60 Opens windows in closed room 61 Susceptible to colds and fevers 62 Afternoon yawner 63 Get “drowsy” often 64 Swollen ankles worse at night 65 Muscle cramps, worse during exercise; “charley-horse” 66 Shortness of breath on exertion 67 Dull pain in chest or radiating into left arm, worse on exertion 68 Bruise easily,”black/blue”spots on arms or legs 69 Tendency to anemia 70 Frequently have “nose bleeds” 71 “Ringing in ears” or noises in head 72 Tension under the breast-bone, or feeling of “tightness” in the chest, gets worse on exertion ----------- GROUP 5 ---------- 73 Dizziness 74 Dry skin 75 Burning feet 76 Blurred vision 77 Itching skin and feet 78 Excessive falling hair 79 Frequent skin rashes 80 Bitter or metallic taste in mouth in the mornings 81 Bowel movements painful or difficult 82 Feelings of worry, dread, or insecurity 83 Feeling queasy; headache over eyes 84 Greasy foods upsets 85 Stools light-colored 86 Skin peels on foot soles 87 Pain between shoulder blades 88 Using laxatives 89 Stools alternate from soft to watery 90 History of gallbladder attacks or gallstones 91 Sneezing attacks 92 Dreaming, nightmares/bad dreams 93 Bad breath (halitosis) 94 Milk products cause distress 95 Sensitive to hot weather 96 Burning or itching anus 97 Crave sweets ----------- GROUP 6 ---------- 98 Loss of taste for meat 99 Lower bowel gas several hours after eating100 Burning stomach sensations, eating relieves101 Coated tongue102 Pass large amounts of foul smelling gas103 Indigestion 1/2-1 hour after eating; may be up to 3-4 hrs.104 Mucus colitis or “irritable bowel”105 Gas shortly after eating106 Stomach “bloating” after eating

ifnh.org Ph(858)488-8932 Fax (858)488-2566 e-mail ifnh@ifnh.org

1 2 3 ----------- GROUP 8 ----------173 Apprehension174 Irritability175 Morbid fears176 Never seems to get well177 Forgetfulness178 Indigestion179 Poor appetite180 Craving for sweets181 Muscular soreness182 Depression; feelings of dread183 Noise sensitivity184 Acoustic hallucinations185 Tendency to cry without reason186 Hair is coarse and/or thinning187 Weakness188 Fatigue189 Skin sensitive to touch190 Tendency towards hives191 Nervousness192 Headache193 Insomnia194 Anxiety195 Anorexia196 Inability to concentrate; confusion197 Frequent stuffy nose; sinus infections198 Allergy to some foods199 Loose joints ----------- FEMALE ONLY ----------200 Very easily fatigued201 Premenstrual tension202 Painful menses203 Depressed feelings before menstruation204 Excessive and prolonged menstruation205 Painful breasts 206 Menstruate too frequently207 Vaginal discharge208 Hysterectomy / ovaries removed209 Menopausal hot flashes210 Menses scanty or missed211 Acne, worse at menses212 Long standing depression ----------- MALE ONLY ---------- 213 Prostate trouble214 Urination difficult or dribbling215 Frequent night-time urination216 Depression217 Pain on inside of legs or heels218 Feeling of incomplete bowel evacuation219 Lack of energy220 Migrating aches and pains 221 Too easily tired222 Avoids activity223 Leg nervousness at night224 Diminished sex drive

1 2 3 ----------- GROUP 7A ----------107 Insomnia108 Nervousness109 Can’t gain weight110 Intolerance to heat111 Highly emotional112 Flush easily113 Night sweats114 Skin is thin and moist115 Inward trembling116 Heart palpitates117 Increased appetite without weight gain118 Pulse races when resting119 Eyelids and face twitch120 Irritable and restless121 Can’t work under pressure ----------- GROUP 7B ----------122 Noticeable weight gain123 Decrease in appetite124 Easily fatigued125 Ringing in ears126 Sleepy during day127 Sensitive to cold128 Dry or scaly skin129 Constipation130 Mental sluggishness131 Hair coarse, falls out132 Headaches upon arising wear off during day133 Pulse slow, below 65134 Frequent urination135 Impaired hearing136 Reduced initiative ----------- GROUP 7C ----------137 Failing memory138 Low blood pressure139 Increased sex drive140 Headaches, “splitting or rending” type141 Decreased sugar tolerance ----------- GROUP 7D ----------142 Abnormal thirst143 Bloating of the abdomen 144 Weight gain around hips or waist145 Sex drive reduced or lacking146 Tendency toward ulcers and/or colitis147 Increased sugar tolerance148 (FEMALE) Menstrual disorders149 (YOUNG GIRLS) Lack of menstrual function ----------- GROUP 7E ----------150 Dizziness151 Headaches152 Hot flashes153 Increased blood pressure154 (FEMALE) Hair growth on face or body155 Sugar in urine (not diabetes)156 (FEMALE) Masculine tendencies ----------- GROUP 7F ----------157 Weakness and/or dizziness158 Chronic fatigue159 Low blood pressure160 Nails weak and/or ridged161 Tendency towards hives162 Arthritic tendencies163 Perspiration increase164 Bowel disorders165 Poor circulation166 Swollen ankles167 Crave salt168 Brown spots or bronzing of skin169 Allergies - tendency to asthma170 Weakness after colds or influenza171 Muscular and nervous exhaustion172 Respiratory disorders

List below your five main physical complaints in order of importance:

1. _________________________________________________________

2. _________________________________________________________

3. _________________________________________________________

4. _________________________________________________________ 5. _________________________________________________________

Notes:

Your Personal Health Goals

At Advanced Family Chiropractic Center, we are not only here to help you with your current health issues, but also want to assist you in any way we can by helping you achieve a much higher level of wellness. To help me serve you in the best way possible, please share your personal goals with me. Together, we will look at these goals and make this your healthiest year yet! Name: __________________________________________ Date: _____/_____/_____ My current physical activities include: ❏ Basketball ❏ Weight Training ❏ Dance ❏ Baseball/Softball ❏ Running ❏ Hockey ❏ Bicycling ❏ Football ❏ Martial Arts ❏ Bowling ❏ Treadmill/Elliptical ❏ Soccer ❏ Golf ❏ StairMaster ❏ Swimming/Water Aerobics ❏ Tennis ❏ Yoga/Pilates ❏ Walking ❏ Other: _____________________________________________________________________________ I would feel so much better if I could ... ❏ Decrease my stress ❏ Increase my flexibility ❏ Decrease my anxiety ❏ Strengthen my core muscles ❏ Sleep better ❏ Improve my posture ❏ Have more energy ❏ Improve workstation ergonomics ❏ Handle my food and/or outdoor allergies ❏ Quit smoking ❏ Lose weight. I would love to lose _____ pounds! ❏ Eliminate caffeine ❏ Eat healthier ❏ Eliminate alcohol ❏ Help with sugar cravings ❏ Decrease fatigue ❏ Start a personalized diet, organic diet or gluten-free diet ❏ Have more time with family ❏ Lower my blood pressure ❏ Lower my cholesterol ❏ Lower my blood sugar ❏ Learn sport-specific exercises. Sport: ________________________________ ❏ Start a new sport/activity: _______________________________________________

❏ Have more time for myself

Women Only: ❏ Decrease PMS symptoms ❏ Decrease PCOS symptoms ❏ Get pregnant ❏ Decrease endometriosis symptoms ❏ Balance my hormones ❏ Control menopausal symptoms

Please brainstorm on any other health goals you have that I can assist you with:

_____________________________________________________________________________________

_____________________________________________________

Thank you for sharing your most personal goals. I look forward to watching your great progress!

Name: _________________________________ Date: _______________ File#________

ADVANCED FAMILY CHIROPRACTIC

Privacy Practices Acknowledgement: HIPAA

As of April 2003, all health care providers are required by law to provide you the patient with a Notice of Privacy Practices. The privacy of your protected health information (PHI) is important to us. We understand that your health information is personal and we are committed to protecting it. We create a record of care and services you receive in our office. We need this record to provide you with quality care and to comply with certain legal requirements. You are being provided a Notice of Privacy Practices which explains how we may use and share PHI about you. If, at anytime, you have questions or concerns related to your protected health information, please feel free to speak with any one of our staff.

Signature on file form

I authorize use of this form on all my insurance submissions.

I authorize release of information to all insurance companies related to my care atAdvanced Family Chiropractic.

I authorize release of all medical / health information from any other provider I haveused previously to Advanced Family Chiropractic and any agent working on their behalf.

I authorize Advanced Family Chiropractic and any agent working on their behalf to obtainpayment from my insurance company and / or attorney.

I authorize payment to be made directly to Advanced Family Chiropractic.

I permit a copy of this authorization to be used in place of the original.

I permit Advanced Family Chiropractic and any agent working on their behalf to contact meby means of the home, work and / or cell phone number(s) I have provided on the patientinformation form.

I permit Advanced Family Chiropractic and any agent working on their behalf to contactme via written communication to my home address given on the patient information form.

I have received the Notice of Privacy Practices and have reviewed it and I have reviewed the signature on file form.

Signature: _______________________________________ Date: ___________________

Name printed: ____________________________________________________________

Dear Patient:

We are happy to have you as a part of our practice. Our general rule for payment is that payment is due

when services are rendered.

This means that you are responsible for payment to us, even if you have insurance which may cover

some of our entire bill.

This agreement applies to both goods and services provided by our office.

We must run our office as a business, in order to be fair to our staff and other patients. This letter

explains our policies about payment. We ask that you agree to these policies as a patient of our office.

If we extend credit to you by permitting you to defer payment until your insurance company considers

the claim or for some other reason, these are the terms and conditions that apply:

1. You are responsible for payment.

2. If you have insurance and our office participates with your insurance, we will comply with all

contractual requirements. You are still responsible for all contractual payments to our

office, such as co-pays and deductibles.

3. We will file electronic forms in accordance with the standard practices of the industry to

assist in obtaining payment.

4. We reserve the right to charge to fill out forms or provide medical correspondence beyond

the usual and necessary submissions to your insurance carrier.

5. We will not charge interest on the bill until at least 90 days have gone by since the date of

service.

6. We ask that you agree to keep us up to date with your current address and phone number.

7. If you ever have a question about a bill from our office, we ask that you let us know within

30 days of receiving the bill. If you do not do so, we will assume the bill is correct.

8. We may charge interest after 90 days. Our interest rate is seven percent (7%) simple

interest per annum, or the maximum permitted by Michigan law, whichever is the lessor.

9. We promise to mail a copy of the bill by first class mail to your last known address on file

before we turn over your account to our attorney to collect your bill.

10. If we do not receive payment, and we need to send your account to our attorney for

collection of the bill, we ask that you agree by signing this letter to pay the cost of the

collection, including court fees and actual attorney fees.

11. If you are having trouble paying your bill, you should immediately talk to the doctor. We try

to work with our patients, to make sure that they can afford our services.

I agree to these terms and conditions regarding payment for services rendered to me as a patient. If I

am the parent of a minor child, I agree to be responsible for payment and agree to these terms on

behalf of my child.

Date: ________________ Signature: ________________________________________________