Don't forget to bring the following items to your appointment (if available):

Dear Thank you for choosing our office. We are EXCITED about helping you enjoy life again without the painful symptoms of peripheral neuropathy! We currently have you scheduled on NOTE: We do our very best to keep on schedule and we do not overbook for that reason. The doctor, the exam room, and about 30 minutes is reserved just for you. To keep you and the other patients on schedule, we recommend that you arrive around 30 minutes before your scheduled appointment time. We promise to do our very best to have you with the doctor within 10 minutes of your scheduled appointment time. Don't forget to bring the following items to your appointment (if available): Enclosed with this letter is a copy of our new patient paperwork. Please fill in as much information as possible before your scheduled appointment. If you have any questions about certain sections, just leave it blank and the doctor will go over them with you during the consultation. If you need to reschedule or cancel your scheduled appointment, as a courtesy, please call us 24 hours before your scheduled appointment time. Thank you again for choosing us to help you and we look forward to meeting you soon! MRI Report & Copy of MRI (CD version preferred) Radiology Report & Copy of x- rays (CD version preferred) Medication List Driver s License Insurance Cards Spouse (if applicable) Yours in Health, Kaitlin Schraub, Office Manager

Name: Address: City: Home Phone: State/Zip Code: Cell Phone: Email Address: Date of Birth: Social Security Number: Marital Status: Age: Gender: Spouse Name: Occupation (Current or Previous): Payment Method: CASH CHECK CREDIT CARD HSA CARD RETIRED? Do You Smoke? YES NO Do You Drink Alcohol? YES NO Packs Per Day: Drinks Per Day: Do You Drink Coffee, Tea, or Soda? YES NO Cups Per Day: Do You Exercise Regularly? YES NO Types & Frequency: Do You Wear: HEEL LIFTS SOLE LIFTS INNER SOLES ARCH SUPPORTS Do You Consume Artificial Sweeteners? YES NO Do You Have High Stress Levels? YES NO INSTRUCTIONS: Please check all that apply FOOT PAIN HAND PAIN NECK PAIN ARTHRITIS IN HANDS POOR WOUND HEALING FOOT SURGERY CHEMOTHERAPY SCIATICA ARTHRITIS IN FEET MORTON S NEUROMA LOW BACK PAIN FOOT NUMBNESS DIABETES HIGH BLOOD PRESSURE PACEMAKER/DEFIBRULATOR BULGING DISC HAND NUMBNESS CANCER HIGH CHOLESTEROL DEGENERATIVE DISCS PINCHED NERVE HERNIATED DISC LEG PAIN VASCULAR PROBLEMS PLANTAR FASCIITIS JOINT REPLACEMENTS POOR CIRCULATION SPINAL STENOSIS EXCESSIVE THIRST/ URINATION IMPLANTED CORD/ BLADDER STIMULATOR

In order of importance, list the health problems you are most interested in getting corrected and how long you ve noticed these problems. 1. Length of time noticed: 2. Length of time noticed: 3. Length of time noticed: Is your balance/ walking affected YES NO If yes, please describe Is there a certain time of day when any of these problems are better or worse? Do you have a pacemaker? Yes No Are you taking any drugs that make you sensitive to sunlight? Yes No List the things you ve done for these problems: Gabapentin Neurontin Lyrica Cymbalta Physical Therapy Motrin Ibuprofen Tylenol Aleve Pain Medications Injections Cream on Hands/Feet Chiropractic Massage Therapy B Vitamins Other: What do you think is causing your problem? Names of all the doctors you have seen for these problems and treatment you received: List anything that makes your condition better: Has your condition: Improved Worsened List anything that makes your condition worse: Stayed the Same How would you describe the symptoms? Check all that apply: Aching Pain Numbness Hot sensations Cramping Stabbing Pain Tingling Throbbing Pain Swelling Sharp Pain Pins & Needles Dead Feeling Burning Tiredness Heavy Feeling Cold Hands/ Feet Electric Shocks Other:

How would you rate your pain in the last week? NO PAIN WORST PAIN POSSIBLE 1 2 3 4 5 6 7 8 9 10 If you had to accept some level of pain after completion of treatment, what would be an acceptable level? NO PAIN WORST PAIN POSSIBLE 1 2 3 4 5 6 7 8 9 10 Is this condition interfering with any of the following? daily sleep work activities housework recreational activities walking standing shopping Please give name, address, and office phone of your primary care physician/ family doctor: Name: Phone: Address: When were you last seen there? May we send them updates on your care? YES NO List ALL allergies or sensitivities to medications, foods, and other items: Item you reacted to: Reaction: List the prescription drugs you are currently taking (or attach a list): Name: Dose (MG or IU) Times Daily List the nutritional supplements you are currently taking (or attach a list): Name: Dose (MG or IU) Times Daily Date of last vaccination: Type:

Please mark your current symptoms on the diagram below. Yellow = burning or cold sensation Green = pain of any kind: sharp, tingling, throbbing Blue = loss of sensation Any areas with sensations not mentioned above please circle and note type of sensation.

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view changes to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about health topics we feel might interest you. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. Conduct normal healthcare operations such as quality assessments and physician s certifications. I have read and understand the Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and or disclosed. Patient Name (Please Print): Signature: Relationship to Patient: Date: INFORMED CONSENT FOR CHIROPRACTIC TREATMENT I understand that x-ray films must remain the property of HealthWorks: A Family Wellness Center. They are kept on file for seven years from my last date of service where they may be seen at any time while I am a patient in this office. I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistants to administer chiropractic care, to work with my condition through the use of adjustments and procedures the doctor deems appropriate. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand if I suspend or terminate my care for any reason, any fees for professional services rendered me will become immediately due and payable according to my signed agreement. The doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I understand that, as in all areas of healthcare, in the practice of chiropractic care there are some risks to treatment, including but not limited to: fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I hereby authorize the doctor to work with my condition through the use of chiropractic adjustments to my spine and extremities as they deems appropriate. By signing below I agree to the above and allow the doctor, affiliated with HealthWorks: A Family Wellness Center, to perform such. This consent will cover the entire course of my treatment. Authorizing Signature: Date: CONSENT TO SEND UNENCRYPTED EMAILS I consent to have my own information sent to me at the supplied email address. I understand that emails are unencrypted. The Neuropathy Relief Center at HealthWorks, 2317 Coit Rd., Ste. B, Plano, TX 75075

Your body heals best with rhythmic care; therefore, your ORIGINALLY SCHEDULED APPOINTMENT is always the one from which you will receive the best correction. M: W Th: F: We will work with you to develop a plan that works for your schedule, and you will receive a printed copy of your calendar. If, for any reason, you need to reschedule an appointment please do so with 24-hour notice. Any missed appointment without prior notice will be charged a no-show fee of $25.00. To receive the care you deserve, please make up all missed appointments as soon as possible. Please arrive early enough to be ready for treatment at your appointment time. Our therapy rooms are scheduled back-to-back, which means that if you re late we may have to reschedule. All adjustments and therapies are performed in an open area. If you have a personal or detailed question to address with the doctors, please make an appointment at the front desk. Please leave all cell phones/ noise making devices in your car or put them on silent mode. Please refrain from making phone calls while in the office and put cell phones away when it is your turn on the table. As a courtesy to all our patients, please refrain from fragrances or heavily scented products on the day of your appointment. I fully understand and consent to the guidelines presented above: Patient Name (Please Print): Signature: Date: The Neuropathy Relief Center at HealthWorks, 2317 Coit Rd., Ste. B, Plano, TX 75075

Restriction of Consent to Use and Disclosure of Protected Health Information Restriction of Consent This notice restricts the consent to use and disclosure of Protected Health Information for: that was signed on: (Date of Consent). Name of Patient (print) I do not want my PHI (Personal Health Information) to be sent to my insurance carrier or any other 2 nd or 3 rd party payor, I want to pay my provider out of pocket for the wellness services I want to receive. Effect of Restriction Protected Health Information that is collected on or after the date on which this form is received by this office will no longer be used or disclosed by this office for the purposes of treatment or payment, or to support day-to-day health care operations of this office as described in the consent form. This restriction of consent will not limit the ability of this office to seek payment for services that it provided under an earlier consent, including the consent specified above or to meet legal obligations related to those services, nor will it affect uses or disclosures that occurred prior to the effective date of this restriction. It is the policy of this office that it will continue to provide treatment for a patient who restricts consent to the use and disclosure of his or her Protected Health Information for the purposes of treatment, payment, or health care operations. Effective Date of Restriction This restriction of consent to use or disclose Protected Health Information is effective on date signed. Printed Name Signature of Patient Date Signature of Patient Representative Date Office Representative Date