N a m e

CARSCN CHIROPRACTIC & dEUPUNCTURE CTINIC3907 CENTRA), AVE. STE. F

HOT SPRINGS, AR 7]I9] I3

Dates.s.fDate of B i r lh

Address . CITY ,SIATE

Occupat ion Where EmployedTelephone: Business ResidenceSpouse's Name Where EmployedC) Marr ied t r S ingle D Widow(er) D Divorced E Separated No. of Chi ldrenPayment : O Cash C Check O Visa t r Master Chargel f th is is an Insurance Cla im, Name of Insufance Company Pol icy #

Pol icy #Name of Major Medical Insurance CompanyPersonal Habits: O Drugs tr Medicat ion D Tobacco D Alcohol t r Cof lee O Vitamins,/M inerals

Cl Exercise tr OtherMedicat ion iaken and reason for tak ino i t

Have You Ever:been hosptialized? O Yes tr No When and why?had surgery? O Yes El No What operations and when?had a major or minor fal l or accident? O Yes O No Whai and when?had a cracked or broken bone? tr Yes D No What and when?

Pre3enl Heallh Problem:ls condition related to accident? D Yes tr No Oate of accident

C Employment t r Auto El OtherHow and when did i t start?

CCLT

What doctors have you seen for th is condit ion? WhenProgress: O Better EJ Worse E The same What gives you relief?What makes lhe condi t ion worse?

To The Pa l len l : P lease l i s t be low the l i ve o r more compla in ts you have, in the order o l impor tance. A lso thelength o f t ime you have had th is compla in t .

How LongHow LongHow LongHow LgngHow Long

Female History: Date ol last menstral cycle Regular - l r reg ularBir th Control Pi l ls E Yes tr No Are you pregnant at th is t ime:Ema i l add ress : Signed:

Date:

' 1 .

2 .J .

NOTICEFull payment lor s€rvices rend€rod 13duo at th6 end ol each visi t , l l lor snyreason th i s r eques t canno t bg me l ,arrangements must be made in advancebolore seeino the doclor.

INSURANCEOn al l Inlurance arsignments $r00.00deductlblr musl be mel In lho beglnningunless priof a.r6n0ements are mad€.

Referred By:

Most patients that come to our office have one of two objectives in mind concerning their health care. Somepatients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the causeof the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh yourneeds and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.n Relief n Conective n Check here is you want the Doctor to select the

Care Care type ol care appropriate for your condition

Date Patient's Signature

lf this is an accident related injury, please fill out the Accident Form. Thank You!

P,eliel GateRelief Care is that care necessary to get rid of yoursymptoms or pain, but not the cause of it. lt is thesame as drying a floor that was getting wet from aleak, but not fixing the leak.

I understand and agree that heatth and accident insuanca policies arc an affangement between an insurance cariet and myself. Fuiheffiorc, I under-stand thal the Doctot's Otfice will prcpare any necessaty reporls and lorms to assist ne in making collection from the insunnce company and that anyamount authorized to be paid dndc y to the Doctois Oft'ice wi be Uedited to my account on receipt. Howevet, I clea y understand and agree.that allservices rcndercd me arb charged diectly to ne and that I am personally responsible fot paymenL I also undetstand that il I suspend or terninate, anyfees for professional seNices rendered me will be inmediately due and payable.

I hereby authorize the Doctor to treat my condition as he ot she deems appropriate. It is understood and agreed the amount paid the Doctot, tor x-rcys,is lot eiamination only and the X-ray negatives will rcmain the property of this olfice, being on file where they may be seen at any time while a patientof this office. The patient also agrces thet he/she is responsible fot all bills incurred at this oflice.

Gorreclive GareCorrective care differs from relief care in that its goalis to get rid of the symptoms or pain while correctingthe cause of the Droblem. Conective care varies inlength ol time, but is more lasting.

DatePatient's Signatwe

Consent to Treat a Minor

Guatdian or Spouse's

Date

6 DOAND PRODUCTS Df. DavdSinosr

Signatwe of Authorizing Care

FoF M ,355 Io Fooder csll 1 .8cG548-3676

FAMILY HEALTH HISTORY'l . Place a CHECKMARK (t/) after any condition that is a PAST or PRESENT health problem

tor YOU or YOUFI FAMILY MEMBERS.2.lt any of the family members are deceased, list their AGES at death, and the CAUSE of

death.

CONDITION YOU FATHER MOTHER SPOUSE. BROTHER(S) SISTER(S) CHILDREN

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Patient. Paront or Guardian'sSignaturo Authorizing Trsatment

Arthritis A OAsthma-Hay Fever D B'BackTrouble

D D

Bursilis tr D

Cancer O O

Conslipation O O

Diabetes A A

Disc Problem O O

Emotional Problems O O

Emphysema O OEpilepsy B 0Headaches D D

Heart Trouble B D

High Blood Pressure , D Dlnsorrnia D DKidney Trouble O BLiver Trouble O Dl igraine O trNervousness O ONeuritis O DPinched Nerve tr D

Scoliosis D A

Sinus Trouble D AStomach Trouble O o

Syphilis D o

Tuberculosis u A

Other tr D

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CARSON CHIROPRCTIC & ACUPUNCTURE C],INIC3907 CENTRA1 AVE. STE. F

HCT SPRINGS, AR 7]I9] I3

PATIENT PAIN & TUNCTION QUESTIONNAIRE

PATIENT NAME:

PTACE AN "X"

DATE:

IN YOUR CURRENT PAIN LEVELI

. L O W PAIN123

Nurdrnes s

MODERATE PAIN( )4( )5( )6

Pins & Needles

INTENSE

Burningxxxxxxxxx

EMERGENCY( ) 10(

((

PAIN7I9

MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE DSSCRIBED SENSATIONS.USE THE APPROPRTATE SYMBOL. MARK STRESS AREAS OF RADIATION.INCI,UDE ALL AFFECTED AREAS .

Stabbing DuI1 Pain***

* *t t

* *

Neck IndexACN Group, lnc. Form Nl-'100

Patient Name

I IRSON CHIROPRICT. l I& ACUPUI{T i t ]RT

3 9 0 i c t t i T R , 4 t A V F i ! l J g , s I t . F| ] O T S P R I N O S , A R 7 1 9 1 3

( 5 0 1 ) 5 2 5 - 7 r 7 1

This questionnaire will give your provider information about how your neck condition affects your everyday life.Please answer every section by ma*ing the one statemeht that applies to you. lf two or more statements in onesection apply, please ma* the one statement that most closely descibes your problem.

Pain lntensityr@ lhave no pain althe moment.O The pain is very mild at the moment.@ The pain c.mes and goes and is moderate.@ The pain is laidy severe at lhe moment.@ The pain is very severe at lhe moment.@ The pain is the wotst imaginable at the moment.

S/eeping@ lhave no trouble sleeping.O My sleep is slighily disturbed (less than t hour sleepless).@ My sle€p is mildly disturbed (1.2 hours sleepless).@ My sleep is modeately disturbed (2.3 hours sleepless).@ My sleep is greatly disturbed (3-5 hours sleepless).@ My sleep is completely disturbed {t7 hours sleepless).

Reading@ | can read as much as | ',rant wilh no neck pain.

O I can read as much as I want wilh slight neck pain.

@ | can read as much as I want wilh modeEte necl pain.

@ | cannol rcad as much as I wanl because of moderate neck pain.

@ | can hafdly read at all because of severe neck pain.

@ lcannot read at allbecause ofneck pain.

ConcentratlonO I can concentrate tully when I want with no dimcufiy.O I crn concentrate fully when I wanl wilh slight diffculty.@ | have a fair degree of dimculty concentrating when I want.

O I have a lot of difficuity concentrating when I wanl

@ I have a great deal ol difficulty conc€nlrating when I wanl,

@ I cannol concentrate at all.

WorkI can do as much wor* as I want.I can only do my usual rvork but no more.l can only do most of my usual rvo but no more.I cannol do my usualwo*.lcan hardly do any work atall.lcannoldo any work al all.

Date

Personat Care@ | can look after myself no.mally without causing extra pain.

O I can look after myself nomally but it causes efia pain.@ lt is pairful to look affer myself and I am slow and careful.@ I need sone help but I manage most of my personal care.@ | need help evefy day in rnost as@ts of self care.

@ | do not get dressed, I wash with diffidllly and stay in bed.

Lifting@ I can lift heavy vJ€ights without exta pain.O I can In he6ry weiohts but it causos exba pain.@ Pain prEvents me fiom lifring heavy weights off $e tloor, but I can manage

if lhey arE convenienty poGilioned {e.9., 0n a table).@ Pain prevents ne from liffng heavy weighti off the tloor, but I can manage

light to medium v€ights if they are con\€niently positjoned.O I can only lifr wry light weights.@ | cannol lift or carry anything at all.

Driving@ | can drive my csr wilhout any n€ck pain.

O I can drive my car as long as I want vJith slight neck pain.@ I can drive my car as lor€ as I want with moderate neck pain.@ I csnnot drive my car as long as I rt/anl because of moderale neck pain.@ | can hadly ddve at all bocause of severe neck pain.

@ | cannot ddve my car at all becaus€ of ne* pain.

Recreation@ | am able to engag8 in all my reqsation activilies without n€ck pain.

O I am able to engage io all my usual |ecreatjon aclivilies with some neck pain.

@ | am able to engage in most but not all my usual recteaton activities b€cause of neck pain.

@ | am only able lo engag€ in a terv ol my usual re$ea0on aclivities bec€use 0f neck paan.(D I can hardly do any recrcatjon aclivities because of necl. pain.

@ I cannot do any ecreation activities at all.

Headaches@ lhave no headaches al all.

O I have slight headaches which come infrequently.

@ I have moderato headaches which come intrcquently.

@ I have moderate headadtes which cofiE I uently.

@ I havs sewr€ h€daches which come frequenuy.

O I have headaches almost all lhe time.

@O@@@@

ACN Gtuup, lac. Usa Oilv ret &27n@3

ruect f---ltndex | |Score I I

Back IndexACN Grcup, l^c Fom 81100

Patient Name

IARSOI I I | | IROPRTiT IC& ACUI l j I { ITURE

3907 cE l r rRAt rv t l , r u t . sTE. FH O T S P R I N 6 5 , A R 7 1 9 1 3

1 5 0 1 ) 5 2 5 - 7 1 7 1

This questionnaire will give your provider information about how your back condition affects your everyday life.Please answer every section by ma*ing the one statement that applies to you. lf two or more statements in onesection apply, please mark the-one statement that most closely describes your problem.

Pain lntensity@ The parn clrnes and goes and ts very mrld.O The pain is mild and does not vary much.@ The pain comes and go€s and is mode€te.O The pain is moderate and does not vary much.@ The pain comes and goes and is very severe.@ The pain is very severe and does not vary much.

Sleeping@ lget no pain in bed.O I get pain in b€d but it does not prevent me fmm sleeling ne .@ Eecause of pain my nomal sleep is pduced by less than 25%.@ Because of pain my normal sleep is rcduced by less than 50%.@ Eecause of pain my norrnal slesp is reduced by less lhan 75%.@ Pain prevents me from sleeping at all.

Sitting@ I can sil in any chair as long as I like.O I can only sit in my favorite chair as long as I like.@ Pain prcvents me lrom sitting more than t hour.@ Pain prevents me from sitting more than 1n hour@ Pain prevents me trom sitting more than 10 minutes.@ I avoid sitting because il increases pain imflEdialely,

Standing@ I can sland as long as I want wilhout pain.

O I have some pain while standino but it does not incteas€ with tim€.@ | cannoi stand for longer than I hour v/ithout inc{easing pain.O I cannot sland for longer than 12 hour nilhout incteasing pain.

@ | cannol stand for longer than 10 minules rvihool inqeasing paao.

@ | avoid slanding because il increases pain immediately.

Date

Personal Care@ | do not have to drange irry way of washing or dressing in order to avoid pain.O I do nol no.mally ciange my way of washing or dressing even though il causes so.ne pain.@ Washing and drossing ineeas€s lhe pain bul I manage not to chango my way of doing it.O Wbshing and dmssing increases lhe pain and | find it necessary to drange my way ol doing it.@ Eecause of the pain lam unabl€ hdo some washing and dressing v/ithout help.@ Because of the pain lam unable to do anywashing and dressing withouthelp.

Lifting@ | can lilt heavy w€ights wiliout extra pain.(D I can lilt heavy weighb but it ceus€s extra pan.

O Pain pl€vsnts m€ from lifting heavy weEhts ofi the floor.@ Pain prevents me from lifting heavy weights ofi the floor, but I can manage

if lhoy arB convenienlly positioned (e.9,, on a hble).(D Pain prevents me lrom liftjng heavy weighls ofi the floor, bul I can manage

lighl to medium w€ights jf trey ae convenienliy positioned.@ lcan only lifl very lightweights.

Traveling@ | get no pain while trav€ling.O I get some pain $ile traveling but none of my usual forms of lravel make it wo|se.@ | get extra pain while traveling but lt do€s not cause me to se€k alternale forms of travel.@ | get extra pain whil€ faveling which causes me to s€ek alternate lonns of travel.@ Pajn resbict all foms of travel except lhat done while lying dorvn.O Pain testricts allfoms of travel.

Social Llfe@ [,ty social lile is nomal and gves me no extra parn.(D My social life is nonnal but inseases lhe dBgre€ of pain.

@ Pain has no signifrcant affeci on my social life apart from limiting ny morc€n€rg€tic int€resls (e.9., dancing, etc).

@ Pain has rostdcted my socjal lile and I do nol go out ve.y often.

@ Pain has rcstriclsd my social life to my home.6 l have hadly any social life because of the pain.

Walking@ lhave no paan while walking.O I have some pain while walking but it doesn't increase with dishnce.@ lcannotwalk more than I mile withoul increasing pain.

O lcannol walk more than 1/2 mile wilhout inffeasing pain.

O lcannotwalk more than 1i4 mile without increasing pain.

@ | cannot walk at all without increasing pain.

Changing degree of pain@ My pain is rapidly getting betterO My pain nuctuates bul overall is delinitely getting better@ My pain seeng to be getting belter but improvement is slor.

@ My pain is neither getting betler or r$rse.@ My p6in is gradually worsening.@ My pain ls mpidly worsening.

ACN Gtoup,lnc Use Onty @v 32'l4A3

aacr f-llndex | |Score i IIndex Score = [Sum of all statements selected / (# ofsections with a statement selected x 5)l x 100