Emmerich Chiro ractic Clinic S.C.6506 NORMANDY LANE. MADISON. WI 53719. PHONE 608-833-2333. FAX 608-826-0996

Name: __ ---::-----:- --=-:--:' .Appt. Date & time: Sex: M F(Last) (First)

Address: City: St: __ Zip: _

Birth Date: ----------- Age: _ Marital Status: D Single DMarried

Employer: Work#: _

Cell #: Home #: Emergency Contact: _

Email: -------------------------------------------Insurance: Member #: Group #: _

X-rays and/or MRI within the last year? Dyes D no If so, where were they taken?

Primary Care Physician: Clinic: Phone: _

Referred by: D Patient D Yellow Pg D Ins Website D Clinic Website D Other _

Work Related? DYes DNo Auto Related? DYes DNo Liability Injury? DYes DNa

** IF YES, SEE RECEPTIONIST **Race (check one): DWhite D Black/African American D Hispanic DAmerican Indian/Alaskan Native DAsianD Other: D I choose not to specify

Ethnicity (check one): DHispanic or Latino DNot Hispanic or Latino D I choose not to specify

Preferred Language (check one): D English D Spanish D Other: _

List any Allergies:D Animals 0 Aspirin 0 Bees 0 Chocolate 0 Dairy 0 Dust D Eggs DLatex DMolds D Ragweed/PollenDRubber D Seasonal Allergies D Shellfish D Soaps 0 Wheat 0 X-Ray Dye 0 Other: _

List All Past Medical History conditions:D Ankle Pain DArm Pain D Arthritis 0 Asthma DBack Pain D Broken Bones D Cancer D Chest Pain DDepressionDDiabetes DDizziness DElbow Pain DEpilepsy 0 Eye/Vision Problems DFainting DFatigue DFoot PainD Genetic Spinal Condition DHand Pain 0 Headaches 0 Hearing Problems DHepatitis D High Blood PressureDHip Pain DHIV D Jaw Pain D Joint Stiffness DKnee Pain DLeg Pain DMenstrual Problems DMid-Back PainDMinor Heart Problem DMultiple Sclerosis DNeck Pain DNeurological Problems DOsteoporosis D PacemakerD Parkinson's D Polio D Prostate Problems D Shoulder Pain D Significant Weight Change D Spinal Cord InjuryD Sprain/Strain D StrokelHeart Attack DOther: _

Drug Allergies: _

List any Surgeries:D Back DBrain DElbow D Foot DHip DKnee DNeck DNeurological D Shoulder DWrist D Other: _

List type of Medications you are taking:DAnxiety 0 Muscle Relaxant 0 Pain Killers _D Insulin D Birth Control 0 Cardiovascular _DAllergy D Seizure 0 Other: _

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Family History Information: (to determine possible hereditary problems)Relation Past and present health problems

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Signature of Patient or Legal Guardian

Prior Chiropractic Care: Clinic(s) and Doctor(s) name: _

History of Accidents:o Auto __ --=---:- 0 Boat 0 Sport ----,- 0 Other/Falls __ ---,--_:-- _

(Date) (Date) (Date) (Date)

Do you currently smoke tobacco of any kind? 0 Yes 0 Former smoker 0 Never been a smokerIf yes, how often do you smoke? 0 Current every day smoker 0 Current sometimes smokerDo you drink alcohol? 0 No 0 Yes - how many per month? _Do you drink caffeine? 0 No 0 Yes - how many cups per day? _Do you exercise? ? 0 No 0 Yes - (what forms and how often): _

If you are a female, are you pregnant? 0 Yes 0 No

Height: Weight: Blood Pressure: _

INFORMED CONSENT FOR CHIROPRACTIC CAREA patient, in corning to the doctor of chiropractic, gives the doctor permission and authority to care for the patient in accordance with thechiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldomcause any problem. In rare cases, underlying physical defects, deformities, or pathologies may render the patient susceptibility to injury.The doctor, of course will not give a chiropractic adjustment, or health care, if he/she is aware that such care may be contraindicated.Again, it is the responsibility of the patient to make it known or to learn through health care procedures whatever he/she is sufferingfrom: latent pathological defects, illnesses, or deformities which would otherwise not corne to the attention of the doctor of chiropractic.The patient should look to the correct specialist for the proper diagnostic and clinical procedures. The doctor of chiropractic provides aspecialized, non-duplicating health service. The doctor of chiropractic is licensed in a special practice and is available to work withother types of providers in your health care regime.

TO THE PATIENTPlease discuss any questions or problems with the doctor before signing this statement of policy. I have read and understand theforegoing. •

Date

Doctor's comments:

Past medical care: