HEALTH. CENTER Main St NE, Suite 101 PO Box 507 Duvall, WA ph fax Dr. Jeffrey P. Metcalf

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1 Welcome To Our Office Name I prefer to be called First MI Last Home Address: Street City Zip Mailing Address: Street City Zip Phone: ( ) ( ) ( ) Home Cell Work Birth : / / Age: Male / Female Marital Status S M W D Social Security #: Spouse s Name: Children (please list - names, ages & sexes) Employer: Type of Work: Emergency Contact Information Name: Relation: Phone: Person Responsible for Account, If Other Than Yourself Name: Relation: D.O.B.: / / Billing Address: Street City Zip Phone: ( ) ( ) ( ) Home Cell Work Employer: S.S. #: How did you hear about our office: Dr. Referral Friend/Family Newspaper Flyer Insurance Company Walk In Internet Other: Whom may we thank for referring you: Our office policy requires payment in full for all services rendered at the time of the visit, unless other arrangements have been made with the Doctor. I authorize the provider to release any information required to process any insurance claims. I have read and agree that the above stated information is correct.

2 About Your Health Case History Name: The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nerve system, that resulted in poor health. Following your exam, your Chiropractor will outline a course of care to begin to correct these layers of damage and recover your innate health potential. Loss of Wellness (Birth - Age 5) : About Your Care Chiropractic provides three types of care. The first is Initial Intensive Care which corrects the most recent layer of Spinal and Neurological damage (VSC). This usually reduces or eliminates the symptoms. Then begins Reconstructive Care which corrects the years of damage that occurred when there were few symptoms. And finally, Chiropractic offers a genuine approach to Wellness Care. All of these options will be explained at your report of findings. Then you ll be able to begin a course of care that fits your health goals. At birth, when your nerve system is first damaged, your wellness begins to decrease and journey to ill health starts. Your Mother s Pregnancy Did your mother... 1] Exercise through her pregnancy? 2] Smoke or drink alcohol? 3] Have a proper diet? 4] Experience any physical and/or mental abuse? 5] Experience any falls/injuries during pregnancy? Your Birth Process 1] Was the delivery long? 2] Was the delivery difficult? 3] Forceps? 4] Caesarean? 5] Breach/cephalic? 6] Home birth? 7] Hospital birth? 8] Mother given drugs during delivery? 9] Was labor induced? Growth and Development (up to age 5) 1] Were you taught how to care for your spine? 2] Did you fall out of bed? 3] Were you a headbanger or rocker? 4] Were you breast fed? 5] Childhood sicknesses? 6] Accidents? 7] Surgery? 8] Drugs? 9] Did you fall while learning to walk? 10] Were you picked on by siblings? 11] Child abuse? 12] Spanking (how)? 13] Pulled ear/chin? 14] Other? 15] Chair pulled out when sat down? 16] Did you fall down the stairs? 17] Were you yanked by your arm? 18] Did you have other traumas? What? When? Patient Comments 1] 2] 3] 4] 5] 1] 2] 3] 4] 5] 6] 7] 8] 9] 1] 2] 3] 4] 5] 6] 7] 8] 9] 10] 11] 12] 13] 14] 15] 16] 17] 18] Chiropractor Comments

3 Case History Name: Loss of Whole Body Health (Age 5 - Present) : At birth, when your nerve system is first damaged, your wellness begins to decrease and journey to ill health starts. (Age 5 - Present) 1]Were you taught proper body movement & care? 2] Have you seen a chiropractor before? 3] Did/do you smoke? 4] Did/do you drink any alcohol? 5] Diet (Do you eat health foods)? 6] Have you ever been in accidents? 7] Have you had surgery and organs removed/ replaced? 8] Drugs? (Prescriptive or non-prescriptive) 9] Teeth problems? 10] Eye problems? 11] Hearing problems? 12] Exercise regularly? 13] Sleeping habits? (nightmares, etc) 14] Did/do you have occupational stress? 15] Physical stress? 16] Mental stress? 17] Hobbies/Sports injuries? 18] Other traumas or problems Patient Comments Chiropractor Comments 1] 2] 3] 4] 5] 6] 7] 8] 9] 10] 11] 12] 13] 14] 15] 16] 17] 18] Symptoms and Ill Health (Present State of Ill Health) Years of untreated damage showed up as acute or chronic symptoms. Headaches Neck Pain Back Pain Nervousness Tension Irritability Present Complaint Dizziness Face Flushed Neck Stiff Pins & Needles in legs Pins & Needles in Arms Numbness in Fingers Numbness in Toes Shortness of Breath Fatigue Depression Lights Bother Eyes Loss of Memory Fever Loss of Smell Loss of Taste Diarrhea Feet Cold Hands Cold Stomach Upset Constipation Cold Sweats Loss of Balance Buzzing in Ears Fainting Major Complaint When did the problem begin? () What happened? What is the mechanism of the injury? Onset (Circle one): Sudden, Gradual, Unknown What positions, activities, or movements make each symptom better or worse? Is it constant? Does it have an impact on sleep, work, hobbies, home life, activities of daily living, domestic duties, enjoyment, etc? Describe the quality of the pain: (Ex: Sharp, dull, aches, burning, throbbing, etc) Does the pain radiate? Left or right? Indicate on the diagram. What is the intensity? (Circle one): (Best) (Worst) What is the frequency, in a percentage of awake time? % For each symptom, are certain times of the day worse? (Circle): Morning Afternoon Evening Wakes me up Unaffected by time of day Please note any medications, treatments, or surgeries related to present condition: Family History Heart Disease Arthritis Cancer Diabetes Other Father s Side Mother s Side Chest Pains Sleeping Problems Ears Ring

4 Consent for Use or Disclosure of Health Information Our Privacy Pledge We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information. We may have to disclose your health information to another heal care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services. We may need to use your health information within our practice for quality control or other operational purposes. We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form. We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notices. Your right to limit uses or disclosures You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. Your right to revoke your authorization You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. I have read your consent policy and agree to its terms. I am also acknowledging that I have received a copy of this notice. Printed Name OFFICE USE ONLY Authorized Provider Representative

5 There are two forms of payment: TIME OF SERVICE - Every time you come in. PAYMENT POLICY OR INSURANCE ASSIGMENT- Co-pay, insurance reimbursement signed over to our clinic, (as explained below). It is our desire to assist our patients whenever possible. The following insurance program allows you, our patient, to receive the care you need without undue financial strain. 1. We will bill your insurance company and accept assignment of benefits during your corrective care period. Direct assignment will be discontinued when you have finished corrective care and a supportive health care program is recommended. We will notify you of the change. 2. You must stay current with your percentage of responsibility. Co-pays are due at the time of service. 3. If you receive payment from your insurance carrier during the period which the clinic has accepted benefits, you are to bring the check within three days of receipt and endorse it over to the clinic. Failure to do so may result in collection action. 4. This clinic does not promise that an insurance company will pay. In the event that the insurance company disputes or rejects the claim, it will be the patient s responsibility to pay all the charges and pursue reimbursement from the insurance company on his/her own. The insurance company has 30 days from billing date to make this decision. Patient payment is expected on any fees over 30 days old. I have read the above provisions and wish to participate in the insurance assignment program. I hereby agree to abide by the provision as specified above.

6 TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our Chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I hereby give my permission to publish my success story in whole or to summarize its contents and any portion of its contents in any publications of Metcalf Chiropractic Health Center. I,, have read and fully understand the above statements. [print name] All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.