LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to SPINOS FAMILY CHIROPRACTIC all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name, but at such doctor and clinic’s expenses. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. Signature of Insured/Guardian Date

Terms of Acceptance The goal of our office is to enable patients to gain control of their health. To attain this we believe communication is the key. There are often topics

that are hard to understand and we hope this document will clarify those issues for you.

Please read the below information and if you have any questions please feel free to ask one of our staff members.

Informed Consent: A patient, in coming to the chiropractic physician, gives the doctor permission and authority to care for the patient in accordance with the

chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course,

will not give any treatment or care if he is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to make it known, or to learn through healthcare procedures whatever he/she is suffering from: latent pathological defects, illnesses or deformities which

would otherwise not come to the attention of the chiropractic physician. The chiropractic physician provides a specialized, non-duplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care

regimen. I understand that if I am accepted as a patient by a physician at SPINOS FAMILY CHIROPRACTIC I am authorizing them to proceed with any treatment that may be necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request.

WOMEN ONLY To the best of my knowledge I am/am NOT pregnant and (give my permission/ don’t give my permission) to x-ray me for diagnostic interpretation.

CONSENT TO EVALUATE AND TREAT A MINOR: _____________________________ being the parent or legal guardian of _________________, have read and fully understand the above terms of

acceptance and hereby grant permission for my child to receive chiropractic care.

COMMUNICATIONS: In the event that we would need to communicate your healthcare information, to whom may we do so?

Spouse____________________________________________________

Children___________________________________________________

Others (Including Family Doctor)___________________________________________________

Would you like us to send information to your family doctor? Yes No May we leave messages on any answering device, i.e. home answering machines or voicemails? Yes No

I, ______________________have read and fully understand the above statements.

ACKNOWLEDGEMENT

I have received the notice of privacy practices (HIPPA) and have been provided an opportunity to discuss my right to privacy.

Print Name:________________________________________

Signature:_________________________________________ Date:_____________________________

3135 New Germany Road Suite 33

Ebensburg, PA 15931 814-419-8445

Patient Information

Name:________________________________________________________________________

Please answer the following questions:

Height_______ ft. ______inches

Weight ________lbs.

Smoking Status ⃝ Current every day smoker ⃝ Current some day smoker ⃝ Former smoker ⃝ Never smoker Do you have any medication allergies? ⃝ No known medication allergies ⃝ Yes Please list: _________________________________________________________________ Are you currently taking any medications? ⃝ Not currently prescribed any medications ⃝ Yes Please list: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Personal/Family History

DISEASE/CONDITION (Please check all that apply and circle the appropriate answer)

Arthritis □ Self Mother Father

Osteoarthritis □ Self Mother Father

Rheumatoid Arthritis □ Self Mother Father

Fibromyalgia □ Self Mother Father

Asthma □ Self Mother Father

Heart Disease □ Self Mother Father

High Blood Pressure □ Self Mother Father

Thyroid Disease □ Self Mother Father

Diabetes □ Self Mother Father

Kidney Disease □ Self Mother Father

Autoimmune Type:________________________ Self Mother Father Cancer Type:______________________________ Self Mother Father Other:____________________________________ Self Mother Father Please list any major surgeries below: DATE _____________________________________________ _______________________ ____________________________________________________________ ______________________________ ____________________________________________________________ ______________________________ ____________________________________________________________ ______________________________ ____________________________________________________________ ______________________________ ____________________________________________________________ ______________________________

Patient Acknowledgement and Receipt of Notice of

Privacy Practices Pursuant to HIPAA and Consent for

Use of Health Information

Name____________________________________ Date______________________ Print Patient’s Name The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy Practices Pursuant to HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual is available upon request. The undersign does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State Law and Federal Law. Dated this __________day of _________________________, 20____ By______________________________________________ Patient’s Signature If patient is a minor or under a guardianship order as defined by State Law: By______________________________________________ Signature of Parent/Guardian (circle one)

Pain Diagram

Please mark the area of injury or discomfort on the chart below, using the appropriate symbols:

Numbness Pins & Needles Burning Aching Stabbing

- - - - - - - - ○ ○ ○ ○ ○ ^ ^ ^ ^ X X X X ꚛ ꚛ ꚛ ꚛ

- - - - - - - - ○ ○ ○ ○ ○ ^ ^ ^ ^ X X X X ꚛ ꚛ ꚛ ꚛ

- - - - - - - - ○ ○ ○ ○ ○ ^ ^ ^ ^ X X X X ꚛ ꚛ ꚛ ꚛ NAME_______________________________________________ DATE_____________________________ No Pain ꟾ ꟾ Worst Possible Pain Please make a slash through this line as to the level of your pain ___________________________________________________________________________

Patient Signature

3135 New Germany Road Suite 33

Ebensburg, PA 15931 814-419-8445

NAME________________________________________________ DATE____________________

It is getting: Improving Staying the same Getting Worse Have you lost time from work? Yes No Can you perform physical work activities? Yes No Please circle all activities which you are currently experiencing problems: Seeing Tasting Smelling Eating Hearing Bathing Grooming Dressing Reading Typing Writing Grasping Holding Pinching Standing Leaning Walking Stooping Squatting Climbing Kneeling Bending Twisting Carrying Lifting Pushing Pulling Reaching Sitting Driving Riding in car Air Travel Sports Exercising Loss of sexual drive Irritable Reclining Restful sleeping Nervous Insomnia Using the toilet Loss of concentration

Complaint area: (Circle One) Neck Mid-Back Low Back Other

This complaint came on: Gradually Immediately The intensity of this complaint is: Minimal Slight Moderate Severe The frequency of this complaint is: Intermittent Occasional Frequent Constant The pain is: Dull Sharp Aching Shooting Spasm Throbbing Burning Numbing Tingling Other ___________________________________________

SPINOS FAMILY CHIROPRACTIC

The pain is located on: Left Side Right Side Both Sides Actions affecting this complaint: Morning Brings On Aggravates Relieves Bending Back Brings On Aggravates Relieves Twisting Left Brings On Aggravates Relieves Sneezing Brings On Aggravates Relieves Lifting Brings On Aggravates Relieves Cold Brings On Aggravates Relieves Medication Brings On Aggravates Relieves

Afternoon Brings On Aggravates Relieves Bending Left Brings On Aggravates Relieves Twisting Right Brings On Aggravates Relieves Straining Brings On Aggravates Relieves Sitting Brings On Aggravates Relieves Resting Brings On Aggravates Relieves Bending Forward Brings On Aggravates Relieves Bending Right Brings On Aggravates Relieves Coughing Brings On Aggravates Relieves Standing Brings On Aggravates Relieves Heat Brings On Aggravates Relieves Lying Down Brings On Aggravates Relieves Can you go to sleep without problems? Yes No Do you awaken because of pain? Yes No Did you have sleep problems before? Yes No

REVISED OSWESTRY DISABILITY INDEX QUESTIONNAIRE

LAST NAME: FIRST NAME: MI: Date:

Please select one answer for each question:

Section 1 - Pain Intensity Section 6 – Standing (Remember, standing is NOT walking.):

0 The pain comes and goes and is very mild. 0 I can stand as long as I want without pain.

0 The pain is mild and does not very much. 0 I have some pain while standing, but it does not increase with time.

0 The pain comes and goes and is moderate. 0 I cannot stand for longer than 1 hour without increasing pain.

0 The pain is moderate and does not very much. 0 I cannot stand for longer than ½ hour without increasing pain.

0 The pain comes and goes and is severe. 0 I cannot stand for longer than 10 minutes without increasing pain.

0 The pain is severe and does not very much. 0 I avoid standing, because it increases the pain straight away.

Section 2 -- Personal Care (Washing, Dressing, etc.) Section 7 -- Sleeping

0 I would not have to change my way of washing or dressing in order to avoid pain.

0 I get no pain in bed.

0 I do not normally change my way of washing or dressing even though it causes some pain.

0 I get pain in bed, but it does not prevent me from sleeping well.

0 Washing and dressing increases the pain, but I manage not to change my way of doing it.

0 Because of pain, my normal night’s sleep is reduced by less than one quarter.

0 Washing and dressing increases the pain and I find it necessary to change my way of doing it.

0 Because of pain, my normal night’s sleep is reduced by less than one half.

0 Because of the pain, I am unable to do some washing and dressing without help.

0 Because of pain, my normal night’s sleep is reduced by less than one three-quarter.

0 Because of the pain, I am unable to do any washing or dressing without help.

0 Pain prevents me from sleeping at all.

Section 3 – Lifting Section 8 – Social Life

0 I can lift heavy weights without extra pain. 0 My social life is normal and gives me no pain.

0 I can lift heavy weights but it gives extra pain. 0 My social life is normal but increases the degree of pain.

0 Pain prevents me from lifting heavy weights off the floor. 0 Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing,etc.

0 Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table.

0 Pain has restricted my social life and I do not go out as often.

0 Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.

0 Pain has restricted my social life to my home.

0 I can only lift very light weights, at the most. 0 I have hardly any social life because of pain.

Section 4 – Walking Section 9– Traveling

0 Pain does not prevent me from walking any distance. 0 I get no pain while traveling.

0 Pain prevents me from walking more than one mile. 0 I get some pain while traveling, but none of my usual forms of travel make it any worse.

0 Pain prevents me from walking more than ½ mile. 0 I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.

0 Pain prevents me from walking more than ¼ mile. 0 I get extra pain while traveling which compels me to seek Alternative forms of travel.

0 I can only walk using a cane or crutches. 0 Pain restricts me for all forms of travel.

0 I am in bed most of the time and have to crawl to the toilet. 0 Pain prevents all forms of travel except if lying down.

Section 5 – Sitting (“Favorite chair” includes a recliner): Section 10 – Changing Degree of Pain

0 I can sit in any chair as long as I like without pain. 0 My pain is rapidly getting better.

0 I can only sit in my favorite chair as long as I like. 0 My pain fluctuates but overall is definitely getting better.

0 Pain prevents me from sitting more than one hour. 0 My pain seems to be getting better but improvement is slow

at the present.

0 Pain prevents me from sitting more than ½ hour. 0 My pain is neither getting better nor worse. 0 Pain prevents me from sitting more than 10 minutes. 0 My pain is gradually worsening.

0 Pain prevents me from sitting. 0 My pain is rapidly worsening.

NECK DISABILITY INDEX QUESTIONNAIRE

LAST NAME: _____________________ FIRST

This questionnaire is designed to help us better understand how your neck pain affects your ability to

life activities.

Please mark the one that most closely describes your present day situation in each section.SECTION 1 - PAIN INTENSITY

�I have no pain at the moment.

�The pain is very mild at the moment.

�The pain is moderate at the moment.

�The pain is fairly severe at the moment.

�The pain is very severe at the moment.

�The pain is the worst imaginable at the moment.

SECTION 2 - PERSONAL CARE (Washing, Dressing,etc.)

�I can look after myself normally without causing extra pain.

�I can look after myself normally, but it causes extra pain.

�It is painful to look after myself, and I am slow andcareful.

�I need some help but manage most of my personal care.

�I need help every day in most aspects of self

�I do not get dressed. I wash with difficulty and stay in bed

SECTION 3 – LIFTING

�I can lift heavy weights without causing extra pain.

�I can lift heavy weights, but it gives me extra

�Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.

�Pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned.

�I can lift only very light weights.

�I cannot lift or carry anything at all.

SECTION 4 – READING

�I can read as much as I want with no neck pain.

�I can read as much as I want with slight neck pain.

�I can read as much as I want with moderate neck pain.

�I can't read as much as I want because of moderate neck pain. �I can't read as much as I want because of severe neck pain.

�I can't read at all.

SECTION 5 – HEADACHES

�I have no headaches at all.

�I have slight headaches that come infrequently.

�I have moderate headaches that come infrequently.

�I have moderate headaches that come frequently.

�I have severe headaches that come frequently.

�I have headaches almost all the time.

NECK DISABILITY INDEX QUESTIONNAIRE

LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________

This questionnaire is designed to help us better understand how your neck pain affects your ability to

lease mark the one that most closely describes your present day situation in each section. SECTION 6 – CONCENTRATION

�I can concentrate fully without difficulty.

�I can concentrate fully with slight difficulty.

�I have a fair degree of difficulty concentrating.

�I have a lot of difficulty concentrating.

�I have a great deal of difficulty concentrating.

The pain is the worst imaginable at the moment. �I can't concentrate at all.

PERSONAL CARE (Washing, Dressing,etc.) SECTION 7 – WORK

look after myself normally without causing extra �I can do as much work as I want.

I can look after myself normally, but it causes extra pain. �I can only do my usual work, but no more.

It is painful to look after myself, and I am slow and �I can do most of my usual work, but no more.

I need some help but manage most of my personal care. �I can't do my usual work.

I need help every day in most aspects of self -care. �I can hardly do any work at all.

wash with difficulty and stay in bed. �I can't do any work at all.

SECTION 8 – DRIVING

I can lift heavy weights without causing extra pain. �I can drive my car without neck pain.

I can lift heavy weights, but it gives me extra pain. �I can drive as long as I want with slight neck pain.

Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie.

�I can drive as long as I want with moderate neck pain.

prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned.

�I can't drive as long as I want because of moderate neck pain.

�I can hardly drive at all because of severe

�I can't drive my car at all because of neck pain.

SECTION 9 – SLEEPING

I can read as much as I want with no neck pain. �I have no trouble sleeping.

want with slight neck pain. �My sleep is slightly disturbed for less than 1 hour.

I can read as much as I want with moderate neck pain. �My sleep is mildly disturbed for up to 1

I can't read as much as I want because of moderate neck �My sleep is moderately disturbed for up to 2

I can't read as much as I want because of severe neck pain. �My sleep is greatly disturbed for up to 3

�My sleep is completely disturbed for up to 5

SECTION 10 – RECREATION

�I have no neck pain during all recreational activities.

I have slight headaches that come infrequently. �I have some neck pain with all recreational activities.

moderate headaches that come infrequently. �I have some neck pain with a few recreational activities.

I have moderate headaches that come frequently. �I have neck pain with most recreational activities.

I have severe headaches that come frequently. �I can hardly do recreational activities due to neck pain.

�I can't do any recreational activities due to neck pain.

Date: ____________________

This questionnaire is designed to help us better understand how your neck pain affects your ability to manage everyday

I can concentrate fully without difficulty.

I can concentrate fully with slight difficulty.

I have a fair degree of difficulty concentrating.

entrating.

I have a great deal of difficulty concentrating.

I can do as much work as I want.

I can only do my usual work, but no more.

I can do most of my usual work, but no more.

I can hardly do any work at all.

I can drive my car without neck pain.

I can drive as long as I want with slight neck pain.

I can drive as long as I want with moderate neck pain.

I can't drive as long as I want because of moderate neck

I can hardly drive at all because of severe neck pain.

I can't drive my car at all because of neck pain.

My sleep is slightly disturbed for less than 1 hour.

My sleep is mildly disturbed for up to 1-2 hours.

My sleep is moderately disturbed for up to 2-3 hours.

My sleep is greatly disturbed for up to 3-5 hours.

My sleep is completely disturbed for up to 5-7 hours.

I have no neck pain during all recreational activities.

I have some neck pain with all recreational activities.

I have some neck pain with a few recreational activities.

I have neck pain with most recreational activities.

I can hardly do recreational activities due to neck pain.

I can't do any recreational activities due to neck pain.

HEADACHE DISABILITY INDEX QUESTIONNAIRE

LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________

Please CHECK the correct response:

I have headaches: � 1 per month �

My headache is: � Mild �

E1 Because of my headaches I feel handicapped.

F2 Because of my headaches I feel restricted in performing my routine daily activities.

E3 No one understands the effect my headaches have on my life.

F4 I restrict my recreational activities (e.g. sports, hobbies) because of my headaches.

E5 My headaches make me angry.

E6 Sometimes I feel that I am going to lose control

F7 Because of my headaches I am less likely to socialize.

E8 My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.

E9 My headaches are so bad that I feel that I am going to go insane.

E10 My outlook on the world is affected by my headaches.

E11 I am afraid to go outside when I feel that a headache is starting.

E12 I feel desperate because of my headaches.

F13 I am concerned that I am paying penalties at work or at home because of my headaches.

E14 My headaches place stress on my relationships with family or friends.

F15 I avoid being around people when I have a headache.

F16 I believe my headaches are making it difficult for me to achieve my goals in life.

F17 I am unable to think clearly because of my headaches.

F18 I get tense (e.g. muscle tension) because of my headaches.

F19 I do not enjoy social gatherings because of my

E20 I feel irritable because of my headaches.

F21 I avoid traveling because of my headaches.

E22 My headaches make me feel confused.

E23 My headaches make me feel frustrated

F24 I find it difficult to read because of my headaches.

F25 I find it difficult to focus my attention away from my headaches and on other things.

HEADACHE DISABILITY INDEX QUESTIONNAIRE

LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________

� more than 1 but less than 4 per month � more than 1 per week

� Moderate � Severe

YES

Because of my headaches I feel handicapped. �

Because of my headaches I feel restricted in performing my routine daily �

one understands the effect my headaches have on my life. �

I restrict my recreational activities (e.g. sports, hobbies) because of my �

�

Sometimes I feel that I am going to lose control because of my headaches. �

Because of my headaches I am less likely to socialize. �

My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.

�

feel that I am going to go insane. �

My outlook on the world is affected by my headaches. �

I am afraid to go outside when I feel that a headache is starting. �

sperate because of my headaches. �

that I am paying penalties at work or at home because of my �

My headaches place stress on my relationships with family or friends. �

I avoid being around people when I have a headache. �

making it difficult for me to achieve my goals in �

I am unable to think clearly because of my headaches. �

I get tense (e.g. muscle tension) because of my headaches. �

I do not enjoy social gatherings because of my headaches. �

I feel irritable because of my headaches. �

I avoid traveling because of my headaches. �

My headaches make me feel confused. �

My headaches make me feel frustrated �

because of my headaches. �

I find it difficult to focus my attention away from my headaches and on other �

LAST NAME: _____________________ FIRST NAME: ___________________ MI: ____ Date: ____________________

more than 1 per week

YES SOMETIMES NO

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