www.nqzchiro.com JEFFRFY G.WACK D.C.

WELCOME TONAZARETH CHIROPRACTIC

Please read and complete the questionnaire on the following pages and sign the 'Terms ofAcceptance' on the back page. If any areas do not apply to you, simpty enter 'N/A' in the space.This information is very important and will help us to get you back on the road to better health

as quickly as possible.

Your first visit will include the following:

l) Consultation with Dr. Wack to review your personal history questionnaire and discussyour current condition or health status.

2) Chiropractic examination/evaluation.

3) Chiropractic x-ray evaluation (if necessary)

4) Specific spinal adjustment(s) in appropriate areas as determined from examinationfindings.

On your second visit we will beleviewing your examination findings and providing you with ourrecommendations for achieving the maximum benefits from your chiropractic care.

FEES: Our office visit fee is $25.00. X-ray fees are additional and vary according to views taken.Payment for ALL services is required at the time of your office visit unless other arrangementshave been agreed upon in advance. The only exceptions are Worker's Comp, Personal Injuryand Highmark Blue Shield patients. We do NOT accept assignment on Medicare patients,therefore all services, including x-rays, must be paid for at the time services are provided. Wewill be happy to print out any account information for you to submit to your provider or to youraccountant at the end ofthe year for tax purposes.

PAYMENT: Payment is accepted in the form of cash, check or credit card. We prefer that youpay by cash or check as there is no fee assessed to our office, but welcome your credit cards if youprefer that method. Advance payments can be made to your account if you prefer to not make apayment at each office visit and our software can easily and accurately keep track of your credit.

2O6 Eost Lown Rosd . Nozoreth, PA 18064 PH- 610-7#-4949 FA,C 6l0-74,.-496/i,

Confidential Patient Health Record

PERSONAL HISTORY

Name: Address:

City: State Zip Code:

Birth Date:

E-Mail:

Age:- Sex EM trFHome Phone:

Business Phone: Circle One: Manied Single Widowed Divorced Separated No. of Children-BusinesVEmployer: Type of Work:

Name of Spouse: Spouse's Employer:

Business Phone: Type of Work:

Name and Number of Emergency Contact: Relationship:

Refened To This Otfice By:

Who ls Responsible For Your Bill, You and E Spouse E lnsurance E Workers' Comp. E Personal Injury

CURRENT HEALTH CONDITION

Purpose of This Appointment

CIher Doctors Seen For This Condition: E Yes E tlo Who?

Type of Treatment: Results:

When Did This Condition Begin? Has This Condition Occured Before? fl Yes E ltols Condition: E Job Related fl Auto Accident E Home Injury E rat fl CIher:

Date of Accident: Time of Accident:

Have You Made A Report of Your Accident To Your Employer: E Yes f ttto

Drugs You Now Take: tr trterve pilts E Pain KillerVMuscle Relaxers E Blood Pressure Medicine

fl lnsulin E other

Do You Weirr a Shoe Lift? E Yes E tltoDo You Suffer From Any Condition Other Than That Which You Are Now Consulting Us?

PAST HEALTH HISTORY

Please Check and Describe any Major Surgery/Operations:

E Appendectomy E Tonsillectomy tr Gall Bladder E Hernia E Back Surgery E Heart

I other

E Broken Bones (description)

Major Accidents or Falls:

Hospitalization (Other Than Above):

Previous Chiropractic Care: E None fl Doctor's Name & Approximate Date of Last Visit

Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questionsmust be answered carefully as these problems can affect your overall course of chiropractic care.

CHEGK ANY OF THE FOLLOWING DISEASES YOU HAUE HAD:

tr Pneumoniatr Rheumatic Fevertr Poliotr Tuberculosistr Whooping Coughtr Anemiatr Measles

tr Mumpstr Small Poxtr Chicken Poxtr DiabetesI Cancertr Heart Diseasetr Thyroid

tr lnfluenzatr Pleurisytr Arthritistr Epilepsytr Mental Disorderstr Hypoglycemiatr Eczema

INTAKEtr Cotfee cups/daytr Tea cups/daytr Alcoholtr Cigarettes _ packs/daytr White Sugar

FEMALES ONLY:When was your last period?

Are you pregnant?tr Yes tr No tr'Not Sure

Please place an (X) on the diagram inthe area(s) of your discomfort.

FAMILY HISTORYThe following members have a sameor similar problem as I do:tr Mothertr Fathertr Brothertr Sistertr Spousetr chitd

Have you been tested HIV positive? tr Yes I No

CHEGK AITIY OF THE FOTLOWING VOU HAVE HAD THE PAST 6 MONTHS:

MUSCUTO.SKETETALtr Low Back PainI Pain Between Shoulderstr Neck Paintr Arm Pain _R _L

-Bothtr Joint Pain/Stiffnesstr Walking Problemstr Ditficult Chewing/Clicking Jaw '

tr GeneralStitfnesstr Hip Pain _R _L _Bothtr Leg Pain _R,-L BothtrKneePain, R L ,Both

ilERVOUS SYSTEMtr Nervoustr Numbnesstr Paralysistr DizzinessI Forgetfulnesstr Confusion/Depressiontl Faintingtr ConvulsionsI Cold/Tingling Extremitiestl Stress

GEl{ERALI Fatiguetr AllergiesI Loss of Sleep Hrs./Nighttr Fevertr Headaches

How Often?

GASTRO.II{TESTI}IALtr Poor/Excessive Appetivetr Excessive Thirsttr Frequent Nauseatr Vomitingtr Diarrheatr Gonstipationtr HemorrhoidsI Liver Problems

tr Gall Bladder Problemstr Weight Trouble _Loss Gaintr AbdominalCrampstr Gas/Bloating After Mealstr HeartburnI Black/Bloody Stool'tr Colitis

GEIIIITO.URIilARYtr Bladder Troubletr PainfuUExcessive Urinationtr Discolored Urine

c-v-Rtr Chest Paintr Short Bleath'tl Blood Pressure Probleinstr lrregular HeartbeatIl Heart Problemstr Lung Problems/Congestiontr Varicose VeinsI Ankle SwellingI Stroke

EElrlT

tr Vision Problemstr Dental Problemstr Sore Throattr Ear AcheVRinging in Earstr Hearing Difficultytr Stutfed Nose/Sinus Problems

MALE/FEMALEtr Menstrual Inegularitytr MenstrualCrampstr Vaginal Pain/lnfectiontr Breast Pain/Lumpstr Prostate/Sexual Dysfunctiontr CIher Problemstr

FRONT BACK

TERMS OFACCEPTANCE

When a person seeks chiropractic healthcare and we accept a person for such care, it isessential that both parties be working toward the same objective.

Chiropractic has only ONE objective. It is important that each patient understand boththe objective and the method that will be used to obtain it. This will prevent any

confusion or disappointment by either party.

. ADJUSTMENT: An adjustment is the specific application of forces to facilitatethe body's correction of a vertebral subluxation. Our chiropractic method ofcorrection is specific spinal adjustments.

. HEALTH: A state of optimal physical, mental and social well-being, not merelythe absence of disease or infirmity.

. VBRTEBRAL SUBLUXATION: A misalignment of one or more of the 24

vertebrae of the spinal column which causes alteration of nerve function andinterference to the transmission of mental impulses from the brain. The result is abody that is not functioning at its full potential and cannot properly heal ormaintain itself.

We do not offer to diagnose or treat any disease or condition. However, if during thecourse of a chiropractic spinal examination, we encounter non-chiropractic or unusualfindings, we will inform you. If you desire advice, diagnosis or treatment for thosefindings, we will recommend that you seek the services of a healthcare provider whospecializes in that field of healthcare. Regardless of what the disease or condition iscalled, we do not offer to treat it nor do we offer advice regarding any treatmentprescribed by another healthcare provider. OUR ONLY OBJECTIVE is the locationand correction of vertebral subluxation which results in the reduction of the expressionof life in the body. Our ONLY method of treatment is specific spinal adjustments.

have read and fullv understand the above statements.(print name)

All questions regarding the doctor's objectives pertaining to my care and my financialresponsibilities for today and future office visits in this office have been answered to mycomplete satisfaction.

I therefore choose to receive chiropractic care at Nazareth Chiropractic on these terms.

(signature) (date)