Patient Information Form BarcodelZ#:

Name: Today's Date:

Please complete the Patient lnformation Form and the Patient lntake Questionnaire. Thank You.

lnsurance and Primary Care Physician (PCP) lnformationMember lD #:Company:

Employer: Group #:

Policyholder's Name:

Policyholder's Date of Birth: I l.

Relationship to Patient: self spouse mother father other

PCP Name:

City:

Phone:

State:

I hereby instruct Fairlawn Family Chiropractic to bill services rendered on my behalf to myinsurance company. I hereby instruct my insurance company to pay Fairlawn Family ChiropracticCenter directly for services rendered. This is a direct assignment of my rights and benefits underthis policy. A photocopy of this assignment shall be considered as effective and valid as theoriginal.

Patient lnformationFull Name:

Address:

City:

State:

Date of Birth:

Soc Sec #. _-__Home Phone:

zip: Cell Phone:

EmailAddress.

Marital Status: Single Married Widowed Divorced Do you have children? Y N how many? _Employer:

Occupation:

Work Phone:

Phone:Emergency Contact:

Did someone refer you to our office? Y N Who referred you?

Spouse/ParenUGuardian lnformationFull Name: Date of Birth: _l_l_

Soc Sec #:Address:

City:

State: zip::

Home Phone:

Cell Phone:

EmailAddress:

Employer: Work Phone:

Patient Signature: Date:

Patient lntake Questionnaire BarcodelZ#:

Name: Today's Date:

Reason For Visit:

tr Pain Symptoms tr Wellness Visit tr Auto Accidenttr Work Related lnjury tr Sports lnjury tr Other lnjury

Date of lnjury:

tr Auto Accident:tr Driver tr Passenger, Front tr Passenger, Rear tr Pedestrian

Were You Wearing Seat Belt? trYes trNo Did You Receive Aid at Scene? trYes trNotrls there a Police Report? trYes trNo Were You Taken to Hospital? trYes trNoDid You See Your PCP? trYes trNo

Type of Car? Year? Was the Car Driveable? trYes trNo

Did You Hit? trAir Bag trSteering Wheel trSide Door trDashboard trWindshield

Describe the Accident:

tr Work Related lnjury:Job Title: Company: How long?

Describe Your Normal Work Activities:

Did You File a Report? trYes trNoDid You See Your PCP? trYes trNo

Were You Taken to Hospital? trYes trNo

Explain in DetailWhat Caused the lnjury:

tr Sports or Other lnjury:Explain in DetailWhat Caused the lnjury:

Where Did the lnjury Occur?

Did You File a Report? trYes trNo Were You Taken to Hospital? trYes trNoDid You See Your PCP? EYes trNo

Page 1 of3

Primary Symptoms: (Check allthat apply)

n Headache ! Migraines ! Neck Pain

! Arm Pain ! Low Back Pain n Hip Painn Soreness ! Discomfort tr Numbness! Fatigue n Weakness n Memory LossI Elbow Pain n Knee Pain n Fever! Other:

! Neck Stiffness! Leg Pain! Tingling! Hearing Loss! Sweating

tr Shoulder Pain! Back Painn Dizziness! Depressed! Sleep Problems

Additional Symptoms:

Where! Neck

Specifically Does it Hurt? (Check allthat apply)

I Upper Back! Right Shouldern Right Legn Eyes

! Lower Back n Left Hipn Right Arm ! Left Elbow! Right Knee D Left Ankle! Chest n Abdomen

! Left Shoulder! Left Leg! Headn Other:

I Mid Backn Left Armtr Left Kneen Ears

I Right Hip! Right Elbown Right Anklen Buttocks

Please Describe the Pain and Place an n'X" on the Picture:Severity:! Mild n Mildto-Mod E Moderate ! Mod-to-Severe

Frequency:! Once ! lntermittent ! Occasional ! Frequent

Quality:! Dull ! Medium n Sharp n Stabbing

The Pain is worse: (Check all that apply)! Morning ! Midday n After Work tr Evening

D Severe

! Constant

I Burning

! Nighttime

Describe on a Scale of 1

Circle One: 1 2

Have you Been TreatedD Yes tr No When?

(mild) to 10 (severe) How You Feel:

345678 10

for this Current Gondition in the Past?By Whom?

What Activities of Daily Living are you unable to perform due to your pain?

! Sleeping ! Walking ! Standing n Sitting ! Running n Climbingn Bathing I Showering ! Dressing ! Shoes n Toileting tr Cleaning! Self Care ! Family Care ! Child Care x Home Care n Driving ! Gardening! Working ! Lifting ! Desk Work E Traveling ! School ! Concentrate

Describe how the pain affects these Activities of Daily Living:

Check the box that describes the pain and Activities of Daily Living (ADL):

EEE@E@@@MMPage 2 of 3

Which hand is dominant? ! Right n Left How old is your current mattress?

What type of bed do you sleep on? ! Regular n Firm I Water (fullwave) ! Water (waveless)

What positions do you sleep in? tr back ! right side ! left side n stomach I floor n chairPrevious chiropractor? Dr.

Family doctor? Dr.

Last visit & reasonLast visit & reason

Other physicians seen or tests performed concerning your main complaint:

trOrthopedic !Osteopath trPhysicalTherapy !Neurologist !Podiatrist !Dentist !OB/GYN !MRl !Xrays! CAT Scan I Nerve Conduction ! Homeopathy ! Massage Therapist ! Other Chiropractor

ADDITIONAL COMPLAI NTS :

PAST HISTORY:

What other conditions have you been treated for? (Exptain in detait)

What Surgeries or Procedures have you had? (Exptain in detait)

Medical History - (Check allthat apply)

You:I Diabetes ! Arthritis n AIDS I Sciatica I Bursitis ! Osteoporosis! Alzheimer tr Kidney Dis. ! Gout ! Amputation n Ulcers ! High Blood PressureE Cancer ! Heart Attack tr Stroke ! COPD I Scoliosis ! Low Blood Pressure! Ulcers ! Deafness I Blindness n Migraines I Disc Disorder ! Neuralgia! Constipation n Diarrhea ! Nausea ! Vomiting ! Varicose Vein ! Convulsions! Fainting ! Sweats I Chills ! Nervousness ! Eczema ! Prostate Trouble! Bleeding tr Tonsillitis tr Earache ! Hemorrhoids I Pregnancy ! Neuro-Muscular Diseasen Other: (Be specific)

Your Family:

List any Gurrent Allergies: (Be specific)

Current Medications You are Taking: (Be specific)

Social Activities:Ll Smoke Cigarettes _# packs per day I Smoke Cigars f I don't smoketl Drink Alcohol Beverages _# per day, or _ # per week r. I don't drink alcohol.

! Beer i Wine I Mixed Drinksn I admit to history of Recreational Drug Use. rr I deny history of Recreational Drug Use.l i I am currently Pregnant. Due Date:ll I exercise regularly.I I experience frequent stress.

Comments:

(Your Signature) (Date) Matthew J. Pramik, DC

Page 3 of 3

(Date)

Informed Gonsent Form

Patient Name Date

Provider Name:

I hereby request and consent to the performance of chiropractic adjustments and otherchiropractic procedures, including examination, tests, various modes of physical therapyand/or diagnostic X-rays, on me (or on the patient named above, for whom I am legallyresponsible) which are recommended by the doctor of chiropractic named above and/orother licensed doctors of chiropractic who now or in the future render treatment to me,while employed by, work for, or at, the office, or at any other related office or clinic.

I have had an opportunity to discuss with the doctor of chiropractic and/or with other officeor clinic personnel the nature, purpose and any risks of chiropractic adjustments andother procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice ofchiropractic there are some risks to treatment, including but not limited to fractures, discinjuries, strokes, dislocations, paralysis and strains/sprains. I do not expect the doctor tobe able to anticipate and explain all risks and complications, and I wish to rely upon thedoctor to exercise judgment during the course of the procedure which the doctor feels atthe time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above explanation of the chiropractic adjustmentand related treatment. By signing below, I state that I have weighed the risks involved inundergoing treatment and have myself decided that it is in my best interest to undergo thechiropractictreatment recommended. Having been informed of the risks, I hereby givemy consent to that treatment. I intend this consent form to cover the entire course oftreatment for my present condition and for any future conditions for which I seektreatment.

Patient Signature:

Barcode #:

Date:

Date:Witness Signature:

Matthew J. Pramik, DC:Fairlawn Family Chiropractic Center2640 West Market Street, Suite 101AFairlawn, Ohio 44333

Date:

HIPAA Notice of Privacy Practices

Patient Name Date

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANDHOW TO GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.This Notice of Privacy Practices descrlbes how we may use and disclose your protected health information to carry out treatment,payment or health care operations and for other purposes that are permitted or required by law. lt also describes your rights to accessand control your protected health information. "Protected health information" is information about you, including demographicinformation, that may identify you and that relates to your past, present or future physical or mental health or condition and relatedhealth care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our noticeat any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, wewill provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you inthe mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health lnformationUses and Disclosures of Protected Health lnformation Based Upon Your Written ConsentYou will be asked by your physician to sign a consent form. Once you have consented to use and disclosure of your protected healthinformation for treatment, payment and health care operations by signing the consent form, your physician will use or disclose yourprotected health information as described in this Section 1. Your protected health information may be used and disclosed by yourphysician, our otfice statf and others outside of our office that are involved in your care and treatment for the purpose of providinghealth care services to you. Your protected health information may also be used and disclosed to pay your health care bills and tosupport the operation of ihe physician's practice. Following are examples of the types of uses and disclosures of your protected healthcare information that the physician's office is permitted to make once you have signed our consent form. These examples are notmeant to be exhaustive but to describe the uses and disclosures thai may be made by our office once you have provided consent.Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and anyrelated services. This includes the coordination or management of your health care with a third party that has already obtained yourpermission to have access to your protected health information. For example, we would disclose your protected health information, asnecessary, to a home health agency that provides care to you. We will also disclose protecied health information to other physicianswho may be treating you when we have the necessary permission from you to disclose your protected health information. Forexample, your protecied health information may be provided to a physician to whom you have been referred to ensure that thephysician has the necessary information to diagnose or treat you. ln addition, we may disclose your protected health information fromtimeto-time to another physician or health care provider (e.9., a specialist or laboratory) who, at the request of your physician,becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.Pavment: Your protected health information will be used, as needed, to obtain payment for your health care services. This mayinclude certain activities that your health insurance plan may undertake before it approves or pays for the health care services werecommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided toyou for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may requirethat your relevant protected health Information be disclosed to the health plan to obtain approval for the hospital admission.Healthcare Operations: We may use or disclose, as-needed, your protecied health information in order to support the businessactivities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee reviewactivities, training of medical students, llcensing, marketing and fundraising activities, and conducting or arranging for other businessactivities. For example, we may disclose your protected health information to medical school students that see patients at our office. lnaddition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician.We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protectedhealth information, as necessary, to contact you to remind you of your appointment. We will share your protected health informationwith third party "business associates" that perform various activities (e.9., billing, transcription services) for the practice. Whenever anarrangement between our office and a business associate involves the use or disclosure of your protected health information, we willhave a written contract that contains terms that will protect the privacy of your protected health rnformation. We may use or discloseyour protected health information, as necessary, to provide you with information about treatment alternatives or other health-relatedbenefits and services that may be of interest to you. We may also use and disclose your protected health information for othermarketing activities. For example, your name and address may be used to send you a newsletter about our practice and the serviceswe offer. We may also send you information about products or services that we believe may be beneflcial to you. You may contact ourPrivacy Contact to request that these materials not be sent to you. We may use or disclose your demographic information and thedates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by ouroffice. lf you do not want to receive these materials, please contact our Privacy Contact and request that these fundraising materialsnot be sent to you.Uses and Disclosures of Protected Health lnformation Based upon Your Written AuthorizationOther uses and disclosures of your protected health information will be made only with your written authorization, unless otheMisepermitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent thatyour physician orthe physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity toObject.We may use and disclose your protected health informaiion in the following instances. You have the opportunity to agree or object tothe use or disclosure of all or part of your protected health information. lf you are not present or able to agree or object to the use ordisclosure of the protected health information, then your physician may, using professionaljudgement, determine whether disclosure isin your best interest. ln this case, only the protected health information that is relevant to your health care will be disclosed.Facilitv Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you arereceiving care, your condition (in general terms), and your religious affiliation. All of this information, except religious affiliation, will bedisclosed to people that ask for you by name. Members of the clergy will be told your religious affiliation.

Page 1 of 2

Others lnvolved in Yo Unless you object, we may disclose to a member of your family, a relative, a close friend or anyother person you identify, your protected health information that directly relates to that person's involvement in your health care. lf youare unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in yourbest interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a

family member, personal representative or any other person that is responsible for your care of your location, general condition ordeath. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disasterrelief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.Emergencies: We may use or disclose your protected health information in an emergency treatment situation. lf this happens, yourphysician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. lf your physician or anotherphysician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtainyour consent, he or she may still use or disclose your protected health information to treat you.Communication Barriers: We may use and disclose your protected health information if your physician or another physician in thepractice aftempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physiciandetermines, using professional judgement, that you intend to consent to use or disclosure under the circumstances.Other Permitted Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to ObjectWe may use or disclose your protected health information in the following situations without your consent or authorizationions:Required Bv Law: We may use or disclose your protected health information to the extent that the use or disclosure is required bylaw. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You willbe notified, as required by law, of any such uses or disclosures.Public Health: We may disclose your protected health information for public health activities and purposes to a public health authoritythat ls permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injuryor disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign governmentagency that is collaborating with the public health authority.Leqal Proceedinqs: We may disclose protected health information in the course of any judicial or administrative proceeding, inresponse to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions inresponse to a subpoena, discovery request or other lawful process.Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for lawenforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limitedinformation requests for identification and locaiion purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurredas a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not onthe Practice's premises) and it is likely that a crime has occurred.

2. Your RiqhtsYou have the rioht to inspect and copv vour orotected health information. This means you may inspect and obtain a copy ofprotected health information about you that is contained in a designated record set for as long as we maintain the protected healthinformation. A "designated record set" contains medical and billing records and any other records that your physician and the practiceuses for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapynotes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, andprotected health information that is subject to law that prohibits access to protected health information. Depending on thecircumstances, a decision to deny access may be reviewable. ln some circumstances, you may have a right to have this decisionreviewed. Please contact our Privacy Contact if you have questions about access to your medical record.You have the rioht to request a restriction of your protected health information. This means you may ask us not to use ordisclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may alsorequest that any part of your protected health information not be disclosed to famlly members or friends who may be involved in yourcare or for notificatlon purposes as described in this Notice of Privacy Practices. Your request must state the specific restrictionrequested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request.lf physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected healthinformation will not be restricted. lf your physician does agree to the requested restriction, we may not use or disclose your protectedhealth information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discussany restriction you wish to request with your physician.You have the riqht to reouest to receive confidential communications from us bv alternative means or at an alternativeL@!ig!L We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as tohow payment will be handled or specification of an alternative address or other method of contact. We will not request an explanationfrom you as to the basis for the request. Please make this request in writing to our Privacy Contact.You mav have the rioht to have vour phvsician amend your protected health information. This means you may request anamendment of protected health information about you in a designated record set for as long as we maintain information. ln certaincases, we may deny your request for an amendment. lf we deny your request for amendment, you have the right to file a statement ofdisagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Pleasecontact our Privacy Contact to determine if you have questions about amending your medical record.You have the riqht to receive an accountinq of certain disclosures we have made. if anv, of vour protected health information.This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice ofPrivacy Practices. lt excludes disclosures we may have made to you, for a facility directory, to family members or friends involved inyour care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations.You have the riqht to obtain a paper copy of this notice from us, upon request.

3. ComplaintsYou may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights by us.You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing acomplaint. You may contact our Privacy Contact for further information about the complaint process.

I HAVE BEEN TOLD ABOUT THE PRIVACY FORM AND IT IS LISTED IN THE WAITING ROOM. I MAY READ IT OR ASK TOTAKE ONE HOME IF I NEED TO.

Patient Signature Date:Page 2 of 2