Patient Information: Name:_______________________________ Date of Birth:_________________________ Gender (m) (f) SSN: _________-________-___________ (Required to bill insurance) Weight:_______ Height:-________ Marital Status: ______________________ Professional Title: ___________________

Contact Information: Address: ____________________________ City:_________________ State: _________ Zipcode:_____________________________ Home Phone: (_____)__________________ Cell Phone: (_____)____________________ EMAIL:

Payment Information: I will be paying cash for care. I have a lien, and am working with an attorney

FILL OUT LIEN AND PROVIDE ALL CONTACT INFO.

I would like my insurance to help pay for care. SSN: of Insured: (self)__________________________ Birth date of Insured:____________________________ Relationship to patient:__________________________

COPY OF CARD AND ID REQUIRED

Assignment and release: I certify that I, and/or my dependents, have insurance coverage with __________________________ and assign directly all insurance benefits and payments to Natural BodyWorks LLC, otherwise payable to me for services. I understand that I am responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I authorize a lien on collection of any case, court action, or reimbursement. X:___________________________________________

Patient Condition: Reason for seeking help: ____________________________________________________________________________ When did this begin: ________________________________________________________________________________ Is your condition worsening? How so?__________________________________________________________________ Have you seen other providers?____ Who?_____________________________________________________________ How often do you experience this condition? Constantly, Frequently, Occasionally, Intermittently (all the time) (most of the time) (some times) (off and on) Describe the feeling: Sharp pain, Dull ache, Shooting pain, Numbness, Burning pain, Tingling On a scale of 1-10, 10 being unbearable how is your pain NOW? ______________ How bad are your symptoms at their BEST: _____ How do you achieve that?_________________________________ How bad are your symptoms at their WORST: ____ What makes it that way?_________________________________ Does your condition interfere with work sleep daily routine recreation Activities that are painful and you avoid: standing sitting lying down walking bending ( ) ___________ climbing or descending stairs Please continue with page two for very important health history information… Page Two, Patient Condition:

Health History: Have you seen any other providers for this condition? ( )yes ( )no What treatments have failed to help? ______________________________________________________________ What has worked? ____________________________________________________________________________ What self care have you done? ( ) rested ( )took medicine I had at home (type?_______________________) ( ) ice packs, ( )heat/bath etc. ( )avoided activities that make it hurt (like what? _______________________) ( ) other ___________________________________________________________________________________ When did you know you needed more help/advice? ________________________________________________

Medications (please list)

Surgeries (please list with dates)

Mark the appropriate squares (x) past or () present condition:

Headaches Neck pops by itself Neck tension/spasms Migraines Dizziness Diabetes Heart condition High blood pressure Osteoporosis History of stroke History of cancer Epilepsy/Convulsions Atrophy Fever Fracture Excessive sweating Knee pain Sciatica Swollen ankles Cold feet Weakness in legs Leg cramps

Nervousness Chronic tiredness Insomnia Sadness Stressed out feel Stuck Worry Acne Eczema Bruise easily Hay Fever/ Sinus troubles Adenoids Hearing loss Poor circulation Ringing in ear/s Ear ache Laryngitis Hoarseness Sore throat Tonsillitis Implants (any) Rotator cuff injury

Bursitis Thyroid condition get sick all the time Asthma Cough (persistent) Difficult breathing Shortness of breath Bronchitis Pleurisy Pneumonia Congestion Influenza Shingles Liver condition Jaundice Gall bladder condition Hemorrhoids (piles) Varicose veins Low blood pressure Arthritis COPD Emphysema

Kidney troubles Ulcers Bloating Stomach troubles Indigestion/Heartburn Gastritis Colitis/IBS Constipation Diarrhea Ruptures/Hernias Cramps (intestinal) Menstrual problems Pregnant? Miscarriages Bed wetting Impotency Change of life symptoms Bladder troubles Difficult urination Painful urination Frequent urination Eye problems

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others

for correction of whatever is malfunctioning in their bodies. We will weigh your needs and desires when recommending

any program of care. Please check the type of care desired so that we may be guided by your wishes whenever possible.

RELIEF CARE: Symptomatic relief of pain or discomfort CORRECTIVE CARE: Correcting and relieving the cause of the problem as well as the symptoms COMPREHENSIVE CARE: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.