1322 E. 15th Street Tulsa, OK 74120, Newark, DE, 19713

Phone: (918) 212.8688 • Fax: 1.866.352.5122Email: drmact@9l8chiropractic.com • Website: 9l8chiropractic.com

Weilness Profile

Practice Member Information piie

Name:^Appointment Date D M 20 Birth Date D M YHome Address:City State ZipHome Phone; May we leavea message? LJYes LJNoCell Phone: May we leave amessage? OYes Q NoWork Phone: May we leave a message? LiYes L_:NoEmail:May we add you to ouremail newsletter and calendar ofevents? C Yes O No (Your email will not be shared)Spouse's name? _____Name(s) and age(s) of children:Occupation:

Doyou primarily: OSit U Stand O Perform repetitive tasksHow did you hear about us?

Healthcare HistoryHave you had previous chiropractic care? UNo UYesWho was your previous Chiropractor?

Where? When?Were X-rays taken in the last 6 months? [_}Yes O NoWhat was the primary reason for consultingthat office?Li Relief Care - Symptom reliefof pain or discomfortL.iCorrective Care - Correcting, relievingand stabilizing spinal, joint and postural issuesI )Weilness Care- Maximizing the body's ability for optimal healing and function

Do you feel your previous chiropractic care was effective? L.) No O YesPlease explain:

Are youwearing: C Heel Lifts [jCustom OrthoticsFamily Doctor:Date and reason of last visit:

May we contactyourfamily doctor regarding yourcare at our office ifnecessary? LJ No U YesNaturopathic Doctor:

Date and reason of last visit:

Other Specialists and healthcare professionals:Name:Professional Designation:Date and reason of last visit:Name:^Professional Designation:Date and reason of last visit: ^ .

When?

® 201-IWGtlncss r^ia Kesource Macerisls Inc. w«9lnes$mediaresources.com

Dr. J. Matthew Grisvvold 9l8chiropractic.com Wellness Profile

Wellness ProfileDo you have a specific concern that brings you in?n No, I'm interested inhaving my nervous system assessed to achieve optimal health and functioning.• Yes:

If yes, please answer the following questions:What isyour primaryarea of complaint today?How long have you been aware ofthis? days weeks months yearsWhere else does this paingo in your body?How often do you experience this? • daily • weekly Q monthly • comes and goes • constantlyOn a scale of I to 10(10 being the worst), how does it feel when it's at itsworst?How would you describe the pain/discomfort?_• Dull QAchy OThrobbing QStabbing (jTight/Stiff QBurning QSharp QOther

What makes it feel worse?What makes it feel better?

Do you notice any other problems in your body when you getthis pain/discomfort?Do you feel your condition getting progressively worse? U No G YesDo you feel your condition can be healed? Q No •Yes _What have you tried that hashelped? U Ice O Heat • Medication lj Massage • Physical Therapy • ChiropracticG Other ; ——;

What have you tried that hflsn't helped? Glee GHeat OMedication OMassage tJPhysical Therapy QChiropracticO Other —

See additional Spinal Nerve Function Form to provide further detail on your Wellness Profile (Pages)

Lifestyle InformationThe human body is designed tobe healthy.The primary system in the body which coordinates health and function is thenervous system.Yaur nervous system is surrounded and protected by the bones of the spine, called vertebrae. Physical,emotional, and chemical stresses, common toourcontemporary lifestyle, can result in misalignment to the spinal column aswell as damage the delicate nervous system.The result is acondition called a Vertebral Subluxation. The remainder of theintake form addresses the possible factors which may contribute tovertebral subluxation in your spine which may be impedingyour body'sability to heal.

PhysicalHeight WeightAre you happy with your current physical appearance and abilitl^? GYes GNoFrequency of exercise/weelc Cardio? G® Gl G2 G3 G^ • 6 07

Weight bearing?. GO Gl G2 G3 G^ G5 G6 07 ^Do you stretch after exercise or after other activities of poor posture? OYes G Sometimes O NoHours ofsleep/night? 0>6 G7-9 Ol0+Do you feel refreshed upon waking? O Always G Sometimes LD BarelyAge of mattress? Do you feel your mattress is appropriate for your sleeping style? GNo GYesWhich position do you sleep? GBack O Belly Side: GRight Gteft GBothNumber of hours spent commuting/week? GO-2 03-J 09-11 012+Number of hours spent at adesk or computer/week? GO 01-5 O6-I0 Gl l-20 O2I-40 IG4I+Number ofhours spent on smart device/tablet/week? GO Ql-S O6-I0 Gll-20 G2I-40 lj4I+Do you perform any repetitive tasks at home oratwork?GNo GYesHave you ever been hospitalized orhad surgery? GNoGYes If yes why and when? ^

Have you ever been in a motor vehicle accident (even if itwas minor)? Q No GYesIfyes,what kindand when?.

Were you evaluated and treated after each accident? O No GYesHave you had any non-vehicle accidents orfalls? Q No G Yes

Paee 2© 2014WbllnessMediaResource Materials Inc. wellnessmediaresources-com «»

91 Schiropractic.com Wellness Profile

Early YearsTo your knowledge, was your delivery difficult? O No OVesU If yes: O Forceps O Vacuum LiCaesarean l_J Breech OOther_

Were you breast fed? CjNo CjYes For how long?Did you experienceemotional trauma as a child? i, jNo;,.jYesWere you ever given antibiotics as a child? L JNo LJYesDid you ever have ear infections as a child? L.!No CjYesAny major childhood illness? L No Yes

Emotional

Rate your current level ofpersono/stress in your life: LjNone CjLow CRate your current level of re/ationsh»p stress in your life: CjNone GLow fRate your current level of financial stress in your life: U None U Low CRate your current level ofhea/th stress in your life: QNone LjLow [Rate your current level offamZ/y stress in your life: UNone [jLow LRate your current level of coreerstress in your life: ONone LJLow '•Do you feel you have a supportive network of friends and family? . . . QYes ljNoDo you fee! you have healthy coping strategies for life stress? O Yes U No

JModerate LJHighjModerate OHighjModerate LJHighjModerate L.)HighJModerate OHighJModerate OHigh

Chemical

Were you vaccinated as achild? ONo OYesAny adverse reactions to vaccines? lJNo i jYesDo you choose to have annual flu shots? ONo OYesDo you take antibiotics? OYes. How often?^

nio+

n 10+nio+

OYes 0 Trying to eliminate from diet[ jYes f 1 Trying to eliminate from dietOYes Q] Trying to eliminate from dietOYes Oi "Frying to eliminate from diet

How many glasses ofwater/day: QO OI-3 i J 4-6 L;'0+How many glasses of caffeinated beverages/day: OO 0^*3 L.) 4-6 LjHow many glasses ofcow's milk, juice and pop/day: OO 0'*3 O 4-6 O 7-9 i_,IO+Do you eat gluten? QNo QYes O Trying toeliminate from dietDo you eatdairy? QNo OYes fj Trying to eliminate from dietDo you eatrefined sugars? (white sugar, white bread and pasta) lJ^® jYes O Trying to eliminate from dietDo you eat boxed/frozen foods? OY®s i j Trying to eliminate from dietDo you choose organic foods? GiNo QYes, which: OVeggies i—;Fruits LJMeats OGrainsDoyou eat any artificial sweeteners? (Splenda, Aspartame, Diet Soda, etc). LJNo i lYesAny food/drink allergies, sensitivities, intolerances? UNo ;_.'Yes_Doyousmoke? (JNo OYes (j Iused tofor years [llwishlAre you or have you been exposed to second hand smoke? . . . . QNo LJYes _ _ _Do you drink alcohol? ONo QYes rjO-6/week G6-l2/week U' +ADo you take a probiotic daily? LjNo jYes, CFU s/dayDo you take vitamin D3 daily? LJNo QYes, lU s/dayDo you take Omega 3 Fish Oils daily? QNo QYes, mg/day fjCapsule QLiqtOther supplements or homeopathics?Any other daily medication and their purpose?

Do you have aplan in place with your medical doctor to wean yourself off of any long term medications? CjNo QYes

OZOUWcllncu Media Source Maccrtils Inc welIneasmediaresourGet.com

GlYesJjYes CJ Iused to for years CJ1 wish Ididn't(JYesQYes GO-6/week fG6-l2/week Gl2+/we€riYes. CFU's/day•Yes. lU's/day•Yes, mg/day fjCapsule QLiquid

l2+/week

Ci^ropractlcJ. Matt'icvv onv-vc4U

Family Health

9 i 8chiropractic.com

<f\<mWeliness Profile

At our clinic we are not only interested inyour health and weliness, but also the health and weliness of the important peoplein your life. Please mention below any health conditions or concerns you may have about your:Children:

Spouse;

Mother;

Father:

Brothers/Sisters;Are you seeking chiropractic care today for:

ij Relief Care - Symptom relief of pain or discomfort

M Corrective Care - Correcting, relieving and stabilizing spinal, joint and postural issuesi_lWeliness Care - Maximizing the body's ability for optimal healing and function

Do you have other concerns we should know about?

Goals <S Consent

What is your primary goal for consulting our clinic?Our goals are to providea detailedassessmentof your current healthstatus and provide to you the resources for ahighly engagedand healthy body which is functioning at its absolute peak potential. Essential is a healthy nervous systemfunctioning free from interference called subluxations. You've taken an important step for your health througha chiropractic evaluation!

Consent to Evaluation

I herebygrant permission to receive a chiropractic evaluationincluding history, spinal scan and examination.Anyfindings will be communicated before consenting to commencementof treatment, if appropriate.

Consenting Adult's Signature

@ ZOHWdlncss Media Resource Maccrials Inc. wellnessme£are$ourees.eom

SPINAL NERVE

918chiropractic.com

ORGANS & GLANDS

The organs and glands listedbelow are linked to thecorresponding sections of thespine and it's spinal nerves.

Parotid Gland • ScalpBase of Skull • EyesLacrimal Gland • Sinuses

Inner, Middle & Outer Ear

Nose • Mouth

Intracranial Blood Vessels

Sympathetic Nervous SystemNeck Muscles • DiaphragmShoulders • Elbows • Arms

Wrists • Hands & FingersTonsils •Vocal Cords

Esophagus • HeartLungs• Chest • Thyroid

Arms • Wrists

Esophagus * Chest • HeartLungs • Trachea • LarynxDiaphragm • StomachGallbladder • Liver

Pancreas • Small Intestine

Spleen • Kidneys 'AppendixAdrenals • Colon • Buttocks

Uterus • Ovaries • Testes

Large Intestine • ColonThighs • Buttocks • Groin

Knees • Legs • FeetReproduccive Organs

Buttocks • Groin • LegsAnkles • Feet • Toes

Prostate Gland • Bladder

Reproductive Organs

SystemsFunction ofSpinal Nerves

ASSOCIATED SYMPTOMS

Please indicate below any symptoms you are currentlyrixperiencingas well as any you have previously experienced.

( ' Sinus & Ear Pain/Infection

i3 Runny Nose &Allergies( j Frequent Head Coldsi_i Sore Throat &Tonsilitis

0 Strep Throat[ 1 Chronic Cough & Croup

10 Difficulty Breathing0; Poor Immunityr j DizzinessScVertigoC : Tinnitus & Ear Fullness

r " Vision Problems

( ; Watery/Dry Eyes0 Chronic Fatigue01 Poor Concentration

01 Depression

Asthma

Bronchitis & Pneumonia

Congestion

Reflux & GERD

Indigestion & Heartburn

Stomach Pains

Ulcers

Gas & Bloating

Jaundice

Liver Conditions

Blood Sugar Dysregulation

irritable Bowel,Colitis, Crohn's

Gas Pain & Constipation

Diarrhea

Hemorrhoids

Bladder infections

Bladder Incontinence

& BedwettingPainful/Excessive Urination

Varicose Veins

Leg Cramping

Resdess Legs

Poor Circulation

& Cold Feet

Anxiety & Stress

Seizures

ADD/ADHD

Thyroid DysfunctionMetabolic Dysfunction

insomnia

High/Low Blood Pressure

Enlarged Lymph Glands

Migraines & Headache

TMJPain

Stiff Neck

Arm Pain

Hand/Finger NumbnessLoss of Grip Stren^h

' ; KidneyStones; ; Gall Bladder Attacks

Skin Conditions & Rashes

' J Menstrual Cramps/PMS. J Infertility

; . Menstrual Dysfunction

0' Rashes & Eczema

0; Hyperactivity

01 Shoulder Pain

0. Midback Pain

1 Rib Pain

Prostate Dysfunction& Impotence

Ovarian Cysts &Endomethosis

Fertility Problems/Loss of Menstruation

Low Back Pain

Hip Pain

Thigh PainNumbness &Tinglesin Legs

Sciatica

i' 1 Pelvic Pain

1_; Knee Pain

0: AnklePain &Sprains10 Foot Pain &Weak Arches

<8ZOI4V^^llncss Media Resource Materials Inc. wdln«smediaresourees.com