Atlanta Natural Health Clinic4633 Buford Hwy. Atlanta, GA 30341

770-455-6767 www.atlantanaturalhealth.com

INTAKE QUESTIONNAIRE

Patient Name: Date:

Address: Date of Birth:

City, State, Zip: Home#:

Gender (circle one): MALE FEMALE Work#:

Primary Care Physician: Referring Physician:

Although your history and symptoms are very important in our analysis of your condition, it is also important forus that you understand:

• We do not treat symptoms or diseases.

• A symptom is an attempt by your body to tell you something.

• We will attempt to find the underlying cause.

• We do not use drugs in this program.

• There is no single "healthy" diet that will work for everyone.

• Just because food is considered "healthy", does not mean it is "healthy" for you.

• Your diet consists of everything you eat, drink, rub on your skin, or inhale.• Our procedures are safe and painless.

Briefly describe the reason for your visit and what you hope to accomplish:

AGE WHEN SYMPTOMS WERE FIRST OBSERVEDD Infant (Age 0-2) D Child (Age 3-5)

Child (Age 6-12) D Adolescent (Age 13-18)D Adult (Age 19-25) D Adult (Age 26-40)C Adult (Age 41 and over)

DID YOU SUFFER FROM ANY TYPE OF PHYSICAL, CHEMICAL OR EMOTIONAL TRAUMA JUST

BEFORE YOUR SYMPTOMS WERE FIRST OBSERVED?

HAVE YOUR SYMPTOMS EVER GONE AWAY FOR ANY PERIOD OF TIME?

FAMILY MEMBERS WITH SIMILAR SYMPTOMSD Mother n FatherD Brother/Sister D GrandparentsD Son/Daughter D SpouseD None

Atlanta Natural Health Clinic4633 Buford Hwy. Atlanta, GA 30341

770-455-6767 www.atlantanaturalhealth.com

FREQUENCY & SEVERITY OF SYMPTOMSD Constant/Chronic with little changeD Present part of the timeD Prevents some normal activitiesn Slight interference with normal life

SYMPTOMS ARE WORSED Outdoors and better indoors

D In the bedroom or when in bed

n During wet or damp weather

D During known pollen seasons

D When exposed to tobacco smoke

D When sweeping or dusting the house

D In air conditioning

T Present most of the timeD Present rarelyD Considerable interference with normal lifeC No interference with normal life

D At nighttime

G During windy weather

D When the weather changes

D In certain rooms or buildings

D With yard work, cut grass, leaves, hay or barns

D In areas with mold or mildew

D In fields or in the country

Tobacco smoke bothers me more than anything else

SYMPTOMS ARE BETTERD After shower or bath

D Indoors

D After taking antihistamines

What makes you feel better?

D In air conditioning

D During or after physical activity

D With allergy shots

ANIMALS, INSECTS AND BIRDS THAT CAUSE SYMPTOMS ON EXPOSURED Dogs D Cats D Rodents (mice, guinea pigs, etc.)

D Horses or Cattle D Rabbits D Birds or Feathers

Q Bees D Other

FOOD RELATED SYMPTOMSD Symptoms flare 5-60 minutes after meals

Q The smell or odor of some foods increases symptoms

D Some foods cause swelling of the mouth or tongue

D Some foods cause upset stomach or vomiting

D Symptoms occur with restaurant salad bars or Asian foods

D Symptoms occur with any regularly eaten food

D Preservatives, additives or food coloring increase symptoms

D Some foods are craved or addictive

D Some foods cause nasal symptoms

D Some foods cause rashes or hives

D Some foods cause diarrhea

D Some foods cause headaches

D Some foods cause asthma

D No problem with foods

Atlanta Natural Health Clinic4633 Buford Hwy. Atlanta, GA 30341

770-455-6767 www.atlantanaturalhealth.com

FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSUREa EggsD Corn

D Peanut

D Shellfish

D Tomato

D Coffee or TeaD None

D Milk

D Wheat

D Pork

D Orange or other citrus

D Yeast

D Other

D Beef

D Soybean

D Fish

D Potato

D Chocolate

CHEMICALS THAT CAUSE SYMPTOMSD Insecticides & pesticidesD Perfumes & cosmetics

D Stove or furnace emissions

D Chemicals in the workplace

D NewsprintD None

D Paints & household cleaners

D Gasoline or automobiles exhaust

D The smell of new fabrics or fabric store

D Laundry detergent

D Other:

WHEN ARE YOUR SYMPTOMS WORSE D Year around

D January

D May

D September

D February

D June

D October

D March

D July

D November

D April

D August

D December

MEDICATIONSDo you take any of the following medications on a regular basis?

D Antihistamines (Benadryl, Actifed, Chlortrimeton, Tylenol Sinus, Tylenol Sleep, Dimetapp,Drixoral, Trimalin,Atarax, Claritin, Allegra, Zyrtec, etc)

3 Bronchodilators (Albuterol, Ventolin, Proventil, Serevent, or OTS's such as Primatine Mist, etc)

D Steroid Inhalers (Asmacort, Flovent, Pulmicort, Beclovent, Aerobid, Advair, etc)

D Nasal Steroids (Beconase, Flonase, Nasacort, Rhinocort, etc)

D Medications that affect the immune system (Prednisone, Imuran, Methotrexate, Cellcept, Cyclosporine,

Tacrolimus, etc)

D ChemotherapyPlease list any medications that you are currently taking:

SMOKINGDo you presently smoke? D Yes D No

If yes, at what age did you start?

If yes, average number of cigarettes per day

Does anyone smoke in your home? D Yes D No

Atlanta Natural Health Clinic4633 Buford Hwy. Atlanta, GA 30341

770-455-6767 www.atlantanaturalhealth.com

PREVIOUS ALLERGY EVALUTIONHave you ever seen an allergist? D Yes D No

Have you had allergy skin testing? D Yes D No

Did you have any positive reaction? D Yes D NoIf yes, please list positive allergens (include any medications) _

Have you ever received allergy injections? D Yes D No

WORK ENVIRONMENTWhat is your occupation?

Are you exposed to chemicals or strong odors at work? D Yes D No

If yes, briefly explain

Are you symptoms worse while at work? D Yes D No

If yes, briefly explain

ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW?

ANYTHING ELSE YOU WOULD LIKE TO ASK?

INFORMED CONSENTFOR BAX 3000 ASSESSMENT

Patient Name Telephone Number

Address City & State

Background: I desire to be tested to determine possible undesirable reactions to various substances that arenatural constituents of my diet, environment or body chemistry. I understand that the testing procedure to beused is not generally employed by the majority of physicians for this purpose. I understand that other methodsof allergy testing and treatment are available. These have been described to me.

Procedures: I understand that this is a non-invasive procedure (the skin is not pierced). A metal clip isattached to the skin to measure electrical conductivity on the hands. I understand that the facility cannotguarantee any results.I choose to be tested with the BAX 3000 electro dermal. I understand that electro dermal testing has not beenscientifically proven to be reliable and that my physician must still rely upon my observations as to the efficacyof the test and any treatment based on the results of this test.

Risks: The procedure is very safe because it measures only changes in the electrical properties of the skin.However, since an electrical signal is used there is a slight risk or electrical burn or shock. Skin irritation orredness may occur at the site of the test. However, any discomfort should be brief. There are generally norisks associated with the substances recommended to bring your body to equilibrium as long as thosesubstances are taken as recommended, but please report any discomfort you may experience from takingthese substances to your examiner or physician. Please report any significant health problems (i.e. Diabetes,High Blood Pressure, etc.) to your physician. I understand that there is a risk factor involved in the treatmentand that sensitivities may increase. I assume all responsibility for the unpredictable immune reactions thatmay lead to increased symptoms. I agree to seek immediate medical attention should this occur andunderstand that this facility does not treat cases of anaphylaxis and I agree to completely disclose allinformation regarding any life threatening allergies or allergies resulting in anaphylaxis.

Questions: I have been provided with the opportunity to ask any pertinent questions I have regarding the BAX3000 testing procedure, protocol or treatment program.

Free to Decline: I understand that I may decline to participate in the BAX 3000 electro dermal testing and canchoose instead to have other allergy testing, including scratch test or blood tests for antibodies.

Important: There is no recognized body of scientific evidence to show that an electrically balanced body ismore likely to be healthier and you have chosen to participate in this assessment with that understanding.Your physician may need to use other forms of testing in the course of your treatment.

Payment of Services: You are responsible for the payment of the normal and necessary fees associated withthe BAX 3000 and remedies, supplements, or herbals recommended as a result of that testing, if purchased inthis clinic. Your physician may need to use other forms of testing in the course of your treatment.I have read and understand the above information about BAX 3000 and my rights and responsibilities andhereby consent to the use of the BAX 3000 System. I consent to the use of clinical reports and results of mycase for study, the purpose of advancing clinical knowledge, research and scientific purposes provided that myidentity is kept confidential.

Date

Name. Signature.

Signature of Parent or Guardian if Patient is a minor

Forms of Payment

We accept cash, personal checks, Visa, Mastercard, Discover, Tradebank, Barter For Less, and Barter Consultants.

Payment is expected at time of service unless other arrangements have been made. Services may be paid for in advance.

Insurance / Third Party Pay

As a service to you, we will be happy to file your insurance claims and accept payment from your insurance company. After

verifying coverage, we will explain what portion of your bill is expected to be paid by your insurance company. It is important to

understand that you are still responsible to pay for services provided to you. If you would like our staff to check your chiropractic

benefits, please present your insurance card when you return these forms and please sign after the following statements. I authorize

the release of health or other information necessary to process any claims. I also authorize payment of chiropractic benefits to be

paid to the Atlanta Natural Health Clinic . ____________________________________________date:______________________

Special Arrangements

We have never denied anyone the benefit of care due to their inability to pay our published fees. Individual contracts can be designed

to help specific financial needs. The most important thing to us is that people are given what they need.

Billing

Billing is taken care of at the front desk unless other arrangements need to be made.

Preferred Chiropractic Doctor (PCD)

Dr. Hurd is a participating provider with a national organization that legally allows us to reduce our fees for participating

members. PCD membership is available to all patients. Reduced fees are only applicable when insurance reimbursement is not going

to be used. Annual fees are $37. You can join in the office or online at www.bewell2.com.

Discounted prepayment plans are also available to PCD members, details are provided on additional forms.

I certify that all information provided is true and complete. I agree to pay the amount invoiced in full. I further agree to pay all costs of collection, including costs of a

collection agency if the account is turned over to a collection agency, and including 15% attorney's fees and court costs in the event this balance is turned over to an

attorney. It is agreed that this agreement will be governed under the law of the State of Georgia. The Atlanta Natural Health Clinic has the option of pursuing an action under this agreement in any court of competent jurisdiction in the State of Georgia and I consent to jurisdiction in the State of Georgia.

Signature of patient: ___________________________________________ Date: ________________________

FINANCIAL AGREEMENT The purpose of this agreement is to clarify your financial responsibilities, supporting you to get the

best results in the shortest amount of time. The following are the most common services we provide:

CONSULTATION

EVALUATION /

EXAM

DIAGNOSTIC

IMAGING (X-RAYS

and InSight scans)

CHIROPRACTIC

ADJUSTMENTS

NUTRITIONAL

RESPONSE

TESTING

NSRT / BAX

HBOT

Bio Cleanse Footbath

Meet with the doctor, discuss your reasons for being

here, review your history

Ascertain the nature and severity of your health prob-

lem. Assess and evaluate your new or current health

status and determine and appropriate course of action

Visualize the location of spinal problems and confirm

other exam findings.

Reduce and remove the Vertebral Subluxation Complex

Access any nutritional imbalances or toxins that may be

contributing to or compromising your body’s ability to

heal and function at it’s optimal state

Stress reduction using Low Level Light Laser Therapy

and homeopathic support.

Mild Hyperbaric Oxygen Therapy to saturate cells with

increased levels of oxygen.

Balance and detoxify the body

First visit, new injuries, or

new condition

First visits, new conditions,

exacerbation's, and progress

examinations

As necessary for 1st visit,

re-injuries and progress

examinations

As indicated by

examination

As indicated by examina-

tion, evaluation and interest

of patient

As indicated by examina-

tion , evaluation and interest

Interest of patient

Interest of patient

No charge

$25. -.$180

$25. -.$180.

$35. - $55.

$120. Initial

$35 Follow Up

$75

$65

$30

PROCEDURE PURPOSE WHEN PERFORMED FEE

fitianta NaturaCtfeaCtfi4633 (BufonfJfwy. Atlanta, g# 30341

770-455-6767wvAv.atfantanaturaffieahh.com

Than^you for -your 'interest in NS^ and the (BJVC Aural

The day of your appointment:

• If possible, delay taking any supplements or unnecessary medications for 24 hours prior to your appointment.

• Please drink a lot of water for 24 hours before your visit. It is optimal to be well hydrated.

• Do not wear pantyhose or clothes with very tight sleeves, as they will interfere with the testing procedures. Ifpossible, please don't wear a black shirt on the day of your visit.

• Do not wear any jewelry that you do not ALWAYS wear. You may wear your wedding ring.

• Do not consume alcohol for 24 hours before your appointment.

• Please do not wear perfume, strong smelling deodorant, fragrances, essential oils, body lotion, aftershave orcologne on the day of your visit, (before or after).

• Please schedule appointment so that you are not being tested or treated during the first three days of yourmenstrual cycle.

• Please eat before your appointment, but not a large meal. It is recommended that you avoid food for a 3 hoursafter your visit. Do not come to the office hungry.

• Do not chew gum, use breath mints, drink anything except water or eat anything after arriving for your visit.

• Not permitted for twelve hours after treatment: Chiropractic, Massage, Acupuncture, Vigorous Exercise, Hot Tub,Sauna, Steam Room or Swimming.

• You may not consume alcohol for twelve hours after treatment.

• You may be given a list of additional things to avoid for twenty four hours after treatment.

• We suggest that you also minimize use of cell phones, T.V., computer and other electronic devices for theremainder of your treatment day.

The restrictions above are designed for to offer the maximum results forhealing and give the body opportunity to accept the changes.

We have designed these suggestions based on years of practical experience. You may be able to break some orall of the rules and do just fine, or you may bend one rule and have to repeat the visit. You will have the bestchance for success if you follow all the suggestions. The restrictions are to be followed for 24 hours, a small

price to pay for a long term benefit.