Schneider Chiropractic & Wellness date:___/___/___ Bruce Schneider, DC

PATIENT HISTORY FORM: Please answer ALL questions completely & accurately.

FULL NAME___________________________________________ AGE __________ DATE OF BIRTH_____/_____/_____ SEX: M F

Marital Status: Single Married Widowed Divorced Separated Other:__________________

Home mailing address( not P.O. Box)______________________________________ City:_______________ State :_____ Zip:________

Cell phone #: _________________________ Work phone #:_________________________ Home phone #:________________________

Email : _____________________ @ ____________________ Children ( # & ages, please): #:________ Ages:_______________________

Work Status: Full-time Part-time Not currently employed Homemaker Retired On disability/disabled

Occupation: __________________________________ . Student Status: FULL-TIME PART-TIME NOT A STUDENT

Family Doctor_______________________________ Family Doctor phone #:________________ Date of last physical:_______________

Who referred you? A Patient__________________ Doctor_________________ Other:_________________ N/A

Emergency contact info: PERSON______________________________Relationship:_________________PHONE___________________

PATIENT / GUARDIAN EMPLOYER ( If patient is a MINOR), _________________________ EMPLOYER’S PHONE _____________

I am currently: INSURED. If so, with:_______________________________________ Not insured at this time

The reason for today’s visit:

*If you have no specific symptom or complaint but request a spinal subluxation evaluation today, Check this box.

and bypass the rest of this section, proceed to next page.

For those of you that do have spinal health concerns, complete the rest of this section below in detail. Thank you.

1. List the Major reason(s) for your visit today and describe what it feels like:(aches ,sharp/dull/tingles/burns/etc.)*

Problem:_____________________________________ feels like: ________________________________________ Cause:_________________________________________________________ When it began: ___________________ Usual pain level (1=minimal,10=Extreme) #___, Does the pain travel & to where? Y N __________________________ How often do you notice it? Daily a few times/week a few times a month a few times/yr. only with certain activity How long does an episode last? ____minutes, ______hours, ______days, _____weeks constant

What activities or factors make it feel worse?___________________________________________________________

What activities or factors make it feel better?___________________________________________________________

2. List any additional reason(s) for your visit today and describe what it feels like:(aches ,sharp/dull/tingles/burns/etc.)*

Problem:_______________________________________ feels like: _______________________________________ Cause:_________________________________________________________ When it began: ___________________ Usual pain level (1=minimal,10=Extreme) #____, Does the pain travel & to where? Y N _________________________ How often do you notice it? Daily a few times/week a few times a month a few times/yr only with certain activity How long does an episode last? ____minutes, ______hours, ______days, _____weeks constant

What activities or factors make it feel worse?____________________________________________________________

What activities or factors make it feel better?____________________________________________________________

3. List any additional reason(s) for your visit today and describe what it feels like:(aches ,sharp/dull/tingles/burns/etc.)*

Problem:_____________________________________ feels like: __________________________________________ Cause:___________________________________________________________ When it began:___________________ Usual pain level (1=minimal,10=Extreme) #___, Does the pain travel & to where? Y N ___________________________ How often do you notice it? Daily a few times/week a few times a month a few times/yr only with certain activity How long does an episode last? ____minutes, ______hours, ______days, _____weeks constant What activities or factors make it feel worse?____________________________________________________________

What activities or factors make it feel better?____________________________________________________________

Please note any previous care provided by other providers for this or a similar problem: (* IF NONE, check this box )

Provider name: __________________________Location:__________________when?_____________for what problem?_______________

Provider name: __________________________Location:__________________when?_____________for what problem?_______________

Provider name: __________________________Location:__________________when?_____________for what problem?_______________

Review of Body systems: record any symptoms you’ve noticed either now or in the past year. Be specific –Thanks

Head and Neck Region headaches/migraine: location __________________________ tension across shoulders dizziness/lightheaded_________________________________ ringing in ears ___________________ difficulty swallowing difficulty speaking/facial numbness/ loss of balance:__________________________ arm/hand weakness: _______________ numbness:________________ tingling:_________________ swollen joints: ______________________________ muscle spasms:___________________________ rapid unexplained weight loss anxiety depression fatigue sinus/allergy

Notes by Dr. ___________________________________________________________________________

Mid Back Region: mid back pain: ______________________ rib pain asthma recurrent lung infections difficulty breathing shortness of breath chest pressure/pain ______________________________ heart problems:__________________________ high blood pressure diabetes or hypoglycemia digestive problems:(gallbladder/stomach)_________________ kidney/liver problems___________________

Notes by Dr. _______________________________________________________________________________

Low Back Region

pain: low back/hips/knees/legs/ankles/feet _______________________ leg/foot weakness:_____________ numbness:__________________ tingling:___________________ cramping in legs/Restless Legs. constipation diarrhea Irritable Bowel Syndrome excess gassiness/bloating frequent urination difficulty emptying bladder weak bladder painful/irregular menstrual cycle hormonal problems fertility issues hemorrhoids erectile dysfunction prostate problems

Notes by Dr. ___________________________________________________________________________

MEDICAL HISTORY INFORMATION:

PREVIOUS /CURRENT ILLNESS: CHECK whatever pertains to you, if two choices given, circle correct one. (* IF NONE, check this box )

_____ High Blood Pressure _____ Liver Disease/Hepatitis _____ Cholesterol _____ Eczema/Psoriasis _____ Heart Disease _____ Seizures _____ Anxiety _____Allergies _____ Hepatitis (type) _____ Inflammatory Bowel Disease _____ Thyroid _____ Asthma _____ Stroke _____ Diabetes / Hypoglycemia _____ Depression _____ Mono/TB _____ Gastric reflux/ulcers _____ Arthritis _____ HIV/AIDS _____ Kidney disease _____ Cancer: (type): ______________________ Autoimmune: (type):___________________ Other: __________________ Notes: _______________________________________________________________________________________________ _____________________________________________________________________________________________________

FAMILY HISTORY :Please check any that apply, who it applies to, age, and note if they are deceased. (* IF NONE, check this box ) Migraines/headaches: _____________________________ Back/neck pain____________________________________ Diabetes_____________________ Cancer (include type) ___________________________________________________ Heart disease ___________________________________ Other:______________________ adopted, no history available

notes:_______________________________________________________________________________________________

Social History: Record your answer using the following key: O=often S=sometimes N=never… for each category. Exercise:____ Alcohol use: ___ Tobacco: type____ Caffeine: ____ High Stress situations:____ Family pressures:____ Financial pressures: ____ Diet/sugar-free products:____ Street drugs:____ List any surgical procedures done, including spinal or joint related. (* IF NONE, check this box ) ________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ List any hospitalizations w/details. Please do not include surgical procedures listed previously): (* IF NONE, check this box )

If yes, explain: ___________________________________________________________________________________________

Patient Name (printed): ___________________________________________

Current Medications & why you take them. (Please include “over the counter” & vitamins, etc.). (* IF NONE, check this box ) 1._______________ for ________________ 2._______________for ________________ 3.__________________for ________________

4._______________for ________________ 5.________________for________________ 6. _________________for ________________

7._______________for ________________ 8. ________________for ________________ 9. _________________for ________________

Other:___________________________________________________________________________________________________.

List any Injuries: (that are not car/vehicle related):______________________________________________________________ _________________________________________________________________________________ (* IF NONE, check this box )

Car/vehicle accidents: [year & type of accident (rear ended, head-on, etc.), type of treatment received] (* IF NONE, check this box ) 1. Year: _________, Type:_____________________ Treatment? By whom? ____________________________________ 2. Year: _________, Type:_____________________ Treatment? By whom? ____________________________________ 3. Year: _________, Type:_____________________ Treatment? By whom? ____________________________________

Other:__________________________________________________________________________________________ ***Attention: Female patients: ARE YOU PREGNANT or ACTIVELY TRYING to become pregnant at this time? YES NO

Consent & Authorizations for Care In order to receive an evaluation and/or care administered by this practice, you must read the following and sign below:

Privacy – The health information gathered and created about you (or your children that are minors) will be used for treatment, payment and medical operations. Our office maintains strict, privacy guidelines concerning the use of your personal health information. You can receive a

copy of our policy upon request. You may ask for restrictions to be placed on release of personal medical information; however our office may

not agree to these restrictions. I present myself (and/or my children) for evaluation, care & management of our spinal health & for no other

reason. I hereby authorize Dr. Bruce Schneider (and/or any of his trained assistants) to examine, take any clinically indicated x-rays and

provide chiropractic care to me (and/or my family) as deemed necessary based on our examination findings. Schneider Chiropractic has my

permission to release to or obtain my records from… my insurance company, attorney, or any of my doctors, if needed.

NOTICE SPECIFICALLY REGARDING CHILDREN

If I ever bring my children to this office for receive care, I am giving written permission for Dr. Bruce Schneider to make healthcare decisions

regarding the Chiropractic care of my child/children since I, the parent/legal guardian listed below may not be present at all of his/her

scheduled visits. I understand that I or another parent/legal guardian must be present for my child’s first appointment. I also understand this

signed consent will be valid until the minor child is 18 years of age, or unless I withdraw this permission in writing.

SIGNATURE AUTHORIZATIONS

I, the undersigned, authorize Dr. Bruce Schneider to provide Chiropractic care to me and/or my minor dependent(s). I, the undersigned,

authorize release of any medical information or other information necessary to process insurance claims for myself or my minor dependent(s).

I, the undersigned, request that payment of authorized Medicare and/or other insurance benefits be made, for me or on my behalf, to Schneider

Chiropractic for any services furnished by Dr. Schneider or staff. I authorize any holder of medical information about me to release to my

insurance carrier and/or Medicare and its agents any information needed to determine these benefits payable for related services. I also give

Schneider Chiropractic permission to obtain my records from my insurance company, attorney(s), or any of my doctors or hospitals/clinics as needed.

FINANCIAL RESPONSIBILITY AND AUTHORIZATION FOR PAYMENT

I understand that I am financially responsible for payment for services rendered by Schneider Chiropractic. I authorize Schneider Chiropractic

to provide Chiropractic care and to release records and/or medical information for the purpose of insurance claims. I assign payment and/or

benefits of said claim(s) directly to Schneider Chiropractic. In the case of Medicare, I understand that this office does not take assignment and

that I will pay this office at time of service and receive reimbursement, if applicable, directly from Medicare. I understand that all charges not

paid by my insurance carrier(s) remain my responsibility. I understand that this office does not extend credit and that all services are required

to be paid at time of service. I understand the if the patient is a minor, the legal guardian signing below assumes financial responsibility for the

cost of services rendered. I also understand that any copy of x-rays at a future date will be at my expense and require pre-payment of $10/plate.

REGARDING RECEIPT OF THIS OFFICE’S HIPAA DOCUMENT

I also acknowledge that I have read and understand this office’s HIPAA policy document & was offered a copy of it. I realize that I may elect

not to keep a copy of it, knowing that it I can elect to download it from the office web site. I attest to the fact that all the information provided

on this form is accurate & truthful and that I have read and understand all the stated policies noted in this document.

SIGNATURE:______________________________________________________ DATE: ________________________

The Doctor and I have adequately discussed the risks involved with treatment that are specific to my condition & other treatment options. I have also provided the above information freely and accurately. I present myself today for no other reason other than evaluation and treatment. Signed after discussion with doctor:_______________________________________________ Date: same as above. (or signature of parent/legal guardian if patient is a minor. )

Schneider Chiropractic

Non-Discrimination Statement Your Rights

Civil rights are personal rights guaranteed and protected by the U.S. Constitution and federal laws enacted by Congress, such as the Civil Rights Act of 1964 and the Americans with Disabilities Act of 1990. Civil rights include protection from unlawful discrimination. Under these laws, all persons in the United States have a right to receive health care and human services in a nondiscriminatory manner.

Our Non-Discrimination Statement Schneider Chiropractic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This practice does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This practice:

Provides information to patients in plain language and in a manner that is accessible and timely.

Provides free services to people with disabilities to communicate effectively with us, including auxiliary aids.

Provides free language assistance services to people whose primary language is not English. If you need these services, contact our Practice’s Compliance Officer, Jessica Hassell. If you believe that Schneider Chiropractic has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Compliance Officer. You can file a grievance in person or by mail, or fax. Address: 81 Glen Rd, Garner, NC 27529 Telephone: 919-661-2225 Fax:919-661-2226 If you need help filing a grievance our Compliance Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Tagline – NC Providers Information of Language Assistance Services

for Individuals with Limited English Proficiency

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-919-661-2225.

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-919-661-2225.

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi

số 1-919-661-2225.

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-919-661-

2225 번으로 전화해 주십시오.

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont roposes

gratuitement. Appelez le 1-919-661-2225.

Arabic: لحوظة نت إذا :م تحدث ك غة، اذكر ت ل إن ال ساعدة خدمات ف م ة ال غوي ل ر ال تواف ك ت مجان ل ال صل .ب م ات رق -661-919-1 ب

2225.

Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau

1-919-661-2225.

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги

перевода. Звоните 1-919-661-2225.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa

wika nang walang bayad. Tumawag sa 1-919-661-2225.

Gujarati: સુચના: જો તમ ેગજુરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-919-661-2225.

Mon-Khmer, Cambodian: ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ

គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-919-661-2225.

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen

zur Verfügung. Rufnummer: 1-919-661-2225.

Hindi: ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके दलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-919-661-2225 पर कॉल करें ।

Laotian: ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-

919-661-2225.

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-919-661-2225

まで、お電話にてご連絡ください。