ChiropracticOfficesofGonstead, Stangl&Arkowski,LLCs□ Dr.MJ Gonstead □ Dr.Melissa Stangl□ Dr.LisaArkowski□ Dr.Jennifer Gonstead503E. Clairemont Avenue ⬥ Eau Claire, WI 54701⬥ 715-832-2223

Date:NEW PATIENTINTAKEName(first) (M) (Last)Address City State ZipPhone(Home) (Cell) (Work)DateofBirth Age Gender □Male □ FemaleEmailAddressRace□ Caucasian/White □ AfricanAmerican/Black□ Asian □ Native American □ OtherEthnicity □Hispanic/Latino □NOTHispanic/LatinoMaritalStatus □ Single □Married □ Separated □Divorced □WidowedSpouse̓sNameChildren□ YES □NO name(s)Employer OccupationEmergencyContact Phone RelationshipHowdidyouhear aboutouroffice?□ insurance□medicalprovider□website□ Facebook□ ad/event□ family/friend:

SOCIALHISTORYSmokingStatus□ Never Smoker□Daily Smoker□OccasionalSmoker□ Former Smoker– quit date:Doyouusenon-smokingtobaccoproducts? □NO□ YESAlcoholStatus □ None □ Casual □Moderate □Heavy □ Beer □Wine □ LiquorCaffeineStatus □ None □ less than 3drinks/day □ 3-6drinks/day □morethan 6drinks/dayExercise□ Never □ Daily □Weekly □Walks □ Runs □ Swims □Weights □ Other:

FAMILYHISTORY-☑ where applicableCONDITION SELF FATHER MOTHER SIBLING GRANDPARENTAneurysmCancer/TumorDiabetesEpilepsy/SeizureHeart DiseaseHighCholesterolHypertensionMultiple SclerosisOsteopenia/porosisStroke

PATIENTHISTORYDATE SURGERY -HOSPITALIZATIONS DATE ACCIDENT-ILLNESS -INJURY

PatientInitials____________

PATIENTNAME DATE

Previous ChiropracticCare □NO □ YES ApproximateLastAppointment:Previous DoctorofChiropracticName/Location:

CurrentHealthCareProvider(s) Location(s)

Doyougrantpermissionto contact theseproviders?□ NO□ YES Please initial here→

Have youhadradiologyimagingwithin the past 2years? □NO □ YES□ X-RAY Region: Date/Location:□MRI □ CT Region: Date/Location:□OTHER Region: Date/Location:

CURRENTMEDICATIONS(RxorOTC),VITAMINS, HERBS ANDSUPPLEMENTSSTARTED NAME DOSE FREQUENCY REASONFORTAKING PRESCRIBEDBY

ALLERGIESANDSENSITIVITIES REACTION

REVIEWOFSYSTEMS– Please circle C=current P=PastGENERAL CARDIOVASCULAR GASTROINTESTINAL ENTC P WeightGain C P ChestPain CP AbdominalPain C P Cold/CongestedC P Weight Loss C P HeartMurmur CP AbnormalStool C P Dizzy/VertigoSKIN/BREAST C P Hypertension C P Appetite⇧⇩ C P Headache/MigraineC P Breast lump/tender C P Palpations CP Changeinbowel C P NosebleedsC P DrySkin/Texture C P SleepApnea CP Constipation C P Throat tender/massC P Nail Changes C P Shortnessofbreath CP Diarrhea C P VisionchangesC P Mole Changes C P Syncope (fainting) CP Heartburn PSYCHIATRICC P Rash/Itching C P Varicosities CP Hemorrhoids C P ADD/ADHDNEUROLOGIC RESPIRATORY CP Indigestion C P AnxietyC P Convulsions C P Asthma CP Nausea/Vomit C P DepressionC P Incoordination C P Cough GENITOURINARY C P BipolarC P Memory C P COPD C P BedWetting IMMUNE/LYMPH/ENDOCRINEC P Neuropathy C P Fever/night sweats CP Bleeding/Discharge C P AnemiaC P Numbness C P Infections CP CycleIrregularities C P Bleeding IssuesC P Paralysis C P Pain/Wheezing CP Difficulty urinating C P Lymphnode large/tenderC P Speech C P Shortnessofbreath CP Libido C P Frequent thirst/hungerC P Tingling C P Pneumonia C P Pain onUrination C P Heat/coldintolerantC P Tremors CP Unusual color/smellUrine C P Thyroid Issues

CP Urgency/FrequencyFEMALES Areyoucurrently pregnant□NO□ YES DueDate: Historyof previousmiscarriage?□NO□ YESMenopause□NO□YES CurrentPAP□NO□YES CurrentMammogram□NO□YES Regular self-breastexams□ NO□YES

PatientInitials____________

PATIENTNAME DATE

HISTORYOFPRESENTCOMPLAINTAreyourpresentcomplaintsdueto anyof the following: □ AutoAccident □ Work Injury □ PersonalInjury □ NoHaveyouhadany recent accidents,falls, or injuries? □No □ Yes approximatedate:Haveyouhadany recent hospitalizationsor newdiagnoses?□No□ YesHaveyouhadanyrecentmajorlife events?□No □ Yes

NECK □NoCurrentComplaintDescribeCurrent Complaint

DateofOnset: □ Acute □ Chronic□ Recurrent □ Sudden□ GradualProvocation (what caused/contributed):Quality: □Ache□ Burn□ Dull□ Pinch/Stab□ Sharp□ Sore□ Spasm□ Stiff□ Throb□ Tight□ OtherRadiation: □ Stay Localized□ Pain Travels/Shoots□ Pain Extendselsewhere □Numbness□ TinglingSeverity: □Minimal (no impairment)□ Slight(someimpairment)□Moderate (ADLsdifficult)□Marked (precludeactivity)Pain Level: (no pain) 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10(worst pain ever, nothing else matters)Timing: □ Intermittent (0-25%)□Occasional (25-50%)□ Frequent (50-75%)□ Constant (75-100%)WhatMakesit better?What Makesit worse?

HEADACHE/MIGRAINE □ NoCurrentComplaintDateofOnset: □ Acute □ Chronic□ Recurrent □ Sudden□ GradualDescribe location ANDquality of symptoms:Severity:□Minimal (no impairment)□ Slight (someimpairment)□Moderate (ADLsdifficult)□ Marked (precludeactivity)Pain Level: (no pain) 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10(worst pain ever, nothing else matters)Timing:□ Daily□Weekly □Monthly□ Constant(75-100%)

MIDBACK □NoCurrentComplaintDescribeCurrent Complaint

DateofOnset: □ Acute □ Chronic□ Recurrent □ Sudden□ GradualProvocation (what caused/contributed):Quality: □Ache□ Burn□ Dull□ Pinch/Stab□ Sharp□ Sore□ Spasm□ Stiff□ Throb□ Tight□ OtherRadiation: □ Stay Localized□ Pain Travels/Shoots□ Pain Extendselsewhere □Numbness□ TinglingSeverity: □Minimal (no impairment)□ Slight(someimpairment)□Moderate (ADLsdifficult)□Marked (precludeactivity)Pain Level: (no pain) 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10(worst pain ever, nothing else matters)Timing: □ Intermittent (0-25%)□Occasional (25-50%)□ Frequent (50-75%)□ Constant (75-100%)WhatMakesit better?What Makesit worse?

LOWBACK/HIP/PELVIS □NoCurrentComplaintDescribeCurrent Complaint

DateofOnset: □ Acute □ Chronic□ Recurrent □ Sudden□ GradualProvocation (what caused/contributed):Quality: □Ache□ Burn□ Dull□ Pinch/Stab□ Sharp□ Sore□ Spasm□ Stiff□ Throb□ Tight□ OtherRadiation: □ Stay Localized□ Pain Travels/Shoots□ Pain Extendselsewhere □Numbness□ TinglingSeverity: □Minimal (no impairment)□ Slight(someimpairment)□Moderate (ADLsdifficult)□Marked (precludeactivity)Pain Level: (no pain) 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10(worst pain ever, nothing else matters)Timing: □ Intermittent (0-25%)□Occasional (25-50%)□ Frequent (50-75%)□ Constant (75-100%)WhatMakesit better?What Makesit worse?Checkifyouexperience□ Upper extremity complaints□ Lower Extremity complaints□Other Complaints:

PatientSignature_______________________________ Date____________

Chiropractic Offices of Gonstead, Stangl, and Arkowski LLCsDr. MJ Gonstead Dr. Melissa Stangl Dr. Lisa Arkowski Dr. Jennifer Gonstead

503 E. Clairemont Ave Eau Claire, WI 54701 (715) 832-2223INSURANCE INFORMATION

A Check this box if you are NOT billing insurance for your chiropractic services (Proceed to Section B)

Patient Name Date of Birth

B By signing below, I do hereby give my consent to the performance of conservative, noninvasivetreatment to the joints and soft tissues. I understand that the procedures my consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy exercises may alsobe used.

Although spinal manipulation/adjustment is considered to be one of the safest, most effective forms of therapyfor musculoskeletal problems, I am aware that there are possible risks and complications associated with theseprocedures as follows: Soreness, Dizziness, Fractures/joint injury, Stroke, and physical therapy burns.

I understand the probability of any of these risks occurring is rare and that tests will be performed on me tominimize the risk of any complication from treatment, and I freely assume these risks. I am aware thatreasonable alternatives to chiropractic procedures are available to me including rest, home application oftherapy, prescription and over the counter medications, exercises, and possibly surgery. I also understand thatthere are beneficial effects associated with chiropractic treatment procedures including decreased pain,improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that Iwill achieve these benefits. I agree to the performance of these procedures by my doctor and such otherperson(s) of the doctor’s choosing. I have read or have had read to me the above explanations ofchiropractic treatment. Any question I have regarding these procedures have been answered to mysatisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decisions voluntarily andfreely.

Patient Signature __________________________________________ Date______________________

Patient Address Patient Phone NumberCity State Zip CodePatient’s Employer Employer PhoneInsurance Company Are you the primary Insurance Holder? Y NIf you’re not the primary insurance holder, who is? (Check below)

Spouse Mother Father OtherPolicy # Group #

Please fill out the information below if you are not the primary insurance holderName of Primary Primary’s DOBPrimary’s Address Primary’s Phone #City State Zip CodePrimary’s Employer Employer’s Phone #

Do you have secondary insurance? Yes NoPolicy # Group #

PAYMENTAGREEMENT

I understand that there is no guarantee that my insurance companiesor pre-paid health plan will cover or pay for all of my charges. Notwithstandingdenial, reduction of benefits for any reason, I understand that I amresponsible for all remaining charges.

Patient Signature ________________________________ Date _______________

Office staff use only: Copy of Patient’s insurance card is on file Staff Initials

RE: Patient: __________________________________________ DOB: __________________

AUTHORIZATION FOR VERBAL COMMUNICATION

Verbal Communication RE: Appointments and Billing

I authorize communication between :______________________________________________

____________________________________________________________________________

(List First and Last Names of Person(s) To Whom Your Information May Be Disclosed, Such asParents, Spouse, Etc).

And the doctor(s)/staff of:

O MJ Gonstead LLC O Stangl Chiropractic & Massage Therapy LLC

O Arkowski Chiropractic LLC O Jennifer Gonstead Chiropractic LLC

AUTHORIZATION TO LEAVE VOICEMAIL/TEXT MESSAGES

Options for messaging contact: RE: Appointments and Billing

O Leave Voicemail/ Text at the Following Number(s)________________________________

__________________________________________________________________________

Cell Phone provider: ______________________________________________ (For textingpurposes)

O Leave messages with the individual whom answers the phone at the provided number(s)

O Anyone O Names of authorized individuals: ___________________________________

This Authorization Will Expire In One Year From Signature Unless Otherwise Indicated Below

O Indefinite O End of Date: ____________________________________ (MM/DD/YYYY)

______________________________________ ______________________

Patient Signature Date

ChiropracticOfficesofGonstead, Stangl&Arkowski,LLCs□ Dr.MJ Gonstead □ Dr.Melissa Stangl□ Dr.LisaArkowski□ Dr.Jennifer Gonstead503E. Clairemont Avenue ⬥ Eau Claire, WI 54701⬥ 715-832-2223

503E. Clairemont Avenue ⬥ Eau Claire, WI 54701⬥ 715-832-2223

ChiropracticOfficesofGonstead, Stangl&Arkowski,LLCs□ Dr.MJ Gonstead □ Dr.Melissa Stangl□ Dr.LisaArkowski□ Dr.Jennifer Gonstead

CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATIONOur 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 disclose your health care information.

• We my have to disclose your health information to another health care provider or a hospital if it is necessaryto 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 potentiallyresponsible for the payment of your services.

• We may need to use your health information within our practice for quality control or other operationalpurposes.

• We may need to use you personal health information such as name, address, and phone number to contactyou with appointment reminders.

We have a more complete notice that provides a detailed description of how your health information may beused or disclosed. You have the right to review that notice before you sign this consent form (164.520). Wereserve the right to change our privacy practices as described in that notice. If we make a change to ourprivacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to callus 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 yourrestrictions, the restriction is binding on us.

Our right to revoke your authorization

You may revoke your consent to us at any time; however, your revocations must be in writing. We will not beable to honor your revocation request if we have already released your health information before we receiveyour request to revoke your authorization. If you were required to give your authorization as a condition ofobtaining insurance, the insurance company may have a right to your health information if they decide tocontest 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 ofthis notice.

_________________________________________ ___________________________________

_________________________________________ ___________________________________

______________________

Patient Signature

Date

Date

Printed Name Authorized Staff Representative

OswestryLowBackPainQuestionnaire Score:_______________

Name:____________________________________________________ Date:_______________________Thisquestionnaire isdesignedtoenable yourchiropractor tounderstandhowmuchyour low backpainhasaffectedyour ability tomanageyoureveryday life. Please answereachsectionbymarkingineachsectionONEBOXthat bestdescribesyourconditiontoday. We realize that youmayfeel thatmorethanonestatementmayrelate toyou,butplease justmarktheboxthatmostcloselydescribesyourconditionasyouarefeelingtoday.

Section1– Pain Intensity□ Thepaincomesandgoesand isverymild.□ Thepain ismildanddoesnotvary much.□ Thepaincomesandgoesand ismoderate.□ Thepain ismoderateanddoesnot vary much.□ Thepaincomesandgoesand issevere.□ Thepain is severeanddoesnot vary much.Section2– PersonalCare□ I donothave to changemywayofwashingordressingtoavoidpain.□ I donot changemywayofwashingordressingeven though itcausesmepain.□ I sometimeschangemywayofwashingordressingbecause itincreasespain.□ I find it necessary to changemywayofwashingordressingbecauseit increasespain.□ Becauseof the pain I amunable todosomewashinganddressingwithout help.□ Becauseof thepain I amunabletodoanywashinganddressingwithout help.Section3–Lifting(skipifyouhavenotattempted liftingsincetheonsetofyourlowbackpain)□ I can lift heavyweightswithout extralowbackpain.□ I can lift heavyweightsbut it causesextrapain.□ Painpreventsmeliftingheavyweightsoff the floor.□ Painpreventsmeliftingheavyweightsoff the floor, but I canmanageif they are conveniently positioned,(e.g. ona table).□ Painpreventsmeliftingheavyweightsbut I canmanagelighttomediumweights if they are conveniently positioned.□ I canonly lift lightweightsat themostdueto lowbackpain.Section4– Walking□ I havenopainwalking.□ I have somepainonwalking,but I can still walkmyrequiredtonormaldistances.□ I cannotwalkmorethan1milewithout increasingpain.□ I cannotwalkmorethan½ milewithout increasingpain.□ I cannot walkmorethan¼ mile without increasingpain□ I cannotwalkat all without increasingpain.Section 5-Sitting□ Sittingdoesnot causemeanypain.□ I can sit aslongasI needprovided I havemychoiceof sittingsurfaces.□ Painprevents me fromsittingmorethan1hour.□ Pain prevents mefromsittingmorethan ½ hour.□ Pain preventsme fromsittingmorethan10minutes.□ Painpreventsmefromsittingat all.

Section 6-Standing□ I can standaslongasIwant without pain.□ I have somepainwith standing.It doesnot increasewith time.□ I cannot stand for longerthan1hourwithout increasingpain.□ I cannotstandfor longerthan ½ hourwithout increasingpain.□ I cannot stand for longer than10minswithout increasingpain.□ I avoid standingbecauseit increasesthepain immediately.

Section 7-Sleeping□ I have nopainwhile in bed.□ I havepain inbed, butit doesnotprevent me fromsleeping.□ Becauseofpain I sleeponly¾ ofnormaltime.□ Becauseofpain I sleeponly½ ofnormaltime.□ Because of painI sleeponly ¼ of normaltime.□ Painpreventsme fromsleepingat all.

Section 8-Social Life□My social life is normal andgivesmenopain.□My social life is normal,but increasesthedegreeof pain.□ Painpreventsme fromparticipating inmoreenergeticactivities (e.g. sports, dancing).□ Painpreventsme fromgoingout veryoften.□ Painhas restrictedmysocial life tomyhome.□ I hardly have any sociallife becauseof pain.

Section 9-Traveling□ I get nopainwhile traveling.□ I get somepainwhile traveling, butnoneofmyusual formsoftravel makeit anyworse.□ I get somepainwhile traveling, but it doesnot compelmetoseekalternative formsof travel.□ I get extrapainwhile traveling that requiresmeto seekalternative formsof travel.□ Pain restricts all formsof travel.□ Painprevents all formsof travel exceptthat done lyingdown.

Section 10-Employment/Homemaking□My normal job/homemakingdutiesdonotcausepain.□My normal job/homeduties causemeextrapain, but I canstillperformall that̓ s requiredofme.□ I canperformmostofmy job/homemakingduties,butpainpreventsme fromperformingmorephysicallystressful activitiese.g. lifting, vacuuming,etc.□ Painprevents me fromdoinganythingbut lightduties.□ Painpreventsme fromeven light duties.□ Pain preventsme fromperformingany job/householdchore.

Reference: TheOswestry Disability Index.Spine 25:2940-2953.2000.

QuadrupleNumericalRatingScale

INSTRUCTIONS:Please circle the numberthat bestdescribesthequestionbeingasked.

NOTE:Please answer the followingquestions in regard toyour BACKPAIN

INSTRUCTIONS:Please markthe diagrambelowto indicate where youareexperiencingpain/symptoms

NeckPainDisabilityIndexQuestionnaire Score:_______________

Name:____________________________________________________ Date:_______________________Thisquestionnaire isdesignedtoenable yourchiropractor tounderstandhowmuchyourneckpainhasaffected yourability tomanageyoureveryday life. Please answereachsectionbymarkingineachsectionONEBOXthat bestdescribesyourconditiontoday. We realize that youmayfeel thatmorethanonestatementmayrelate toyou,butplease justmarktheboxthatmostcloselydescribesyourconditionasyouarefeelingtoday.

Section1– Pain Intensity□ I havenopainat themoment.□ Thepain isverymildat the moment.□ Thepain ismoderate at the moment.□ Thepain isfairly severe at the moment.□ Thepain isvery severe at themoment.□ Thepain istheworst imaginableat the moment.

Section2–PersonalCare(Washing, Dressing,etc.)□ I can lookafter myselfwithout causingextrapain.□ I can lookafter myselfnormally but it causesextrapain.□ It is painfulto lookafter myselfandI amslowandcareful.□ I needsomehelpbutmanagemostofmypersonal care.□ I needhelpevery day inmostaspectsof self-care.□ I donot getdress,I washwithdifficulty and stay inbed.

Section3– Lifting□ I can lift heavyweightswithout extra pain.□ I can lift heavyweightsbutit givesextrapain.□ Painpreventsmeliftingheavyweightsoff the floor, but I canmanageif they are conveniently positioned,(e.g. ona table).□ Painpreventsme liftingheavyweights, but I canmanagelighttomediumweights if they are conveniently positioned.□ I can lift very lightweights.□ I cannot listor carry anythingat all.

Section4–Reading□ I can readasmuchasIwant towith nopaininmyneck.□ I can readasmuchas Iwant to with slightpain inmyneck.□ I can readasmuchasIwant towith moderatepaininmyneck.□ I cannot readasmuchasIwant becauseofmoderatepain inmyneck.□ I cannot readasmuchasIwant becauseof severepain inmyneck.□ I cannot readat all becauseofpain inmyneck.

Section 5-Headaches□ I have noheadachesat all.□ I have slight headacheswhich comeinfrequently.□ I havemoderateheadacheswhich comeinfrequently.□ I havemoderateheadacheswhich comefrequently.□ I have severeheadacheswhich comefrequently.□ I haveheadachesalmostall the time.

Section 6-Concentration□ I canconcentratefully whenIwant towith nodifficulty.□ I canconcentrate fullywhen Iwant towith slightdifficulty.□ I have a fair degreeof difficulty inconcentratingwhen Iwant to.□ I have a lot of difficulty inconcentratingwhen Iwant to.□ I have a greatdeal ofdifficulty in concentratingwhen Iwant to.□ I cannotconcentrateat all.

Section7– Work□ I candoasmuchasIwant to.□ I canonlydomyusualwork,butnomore.□I candomostofmyusualwork,butnomore.□ I cannotdomyusualwork.□ I canhardlydoanyworkat all.□ I cannot doanyworkat all.

Section 8-Driving□ I candrivewithout anyneckpain.□I candrivemycar as longas Iwantwith slightpain inmyneck.□ I candrivemycar aslongas Iwantwith moderatepain inmyneck.□ I cannotdrivemycar aslongasIwant becauseofmoderatepain inmyneck.□ I canhardly drive at all becauseof severepain inmyneck.□ I cannotdrivemycar at all becauseof neckpain.

Section 9-Sleeping□ I haveno trouble sleeping.□My sleep isslightly disturbed(less that 1hoursleepless).□My sleep ismildlydisturbed (1-2hourssleepless).□My sleep ismoderatelydisturbed (2-3hourssleepless).□My sleep isgreatlydisturbed (3-5hours sleepless).□My sleep is completelydisturbed (5-7hourssleepless).

Section 10-Recreation□I amable to engagein all ofmyrecreational activities with noneckpain at all.□ I amable to engagein all ofmyrecreational activities with somepain inmyneck.□ I amable to engageinmost,but not all ofmyrecreationalactivities becauseofneckpain.□ I amable to engagein a fewofmyrecreational activitiesbecauseofpain inmyneck.□ I canhardly doany recreational activities becauseof paininmyneck.□ I cannotdoanyofmyrecreational activities at all.

TheNeckDisability Index:Astudyof reliability andvalidity. J Manipulative PhysiolTher1991;14:409-415

QuadrupleNumericalRatingScale

INSTRUCTIONS:Please circle the numberthat bestdescribesthequestionbeingasked.

NOTE:Please answer the followingquestions in regard toyourNECKPAIN

INSTRUCTIONS:Please markthe diagrambelowto indicate where youareexperiencingpain/symptoms

Chiropractic Offices of Gonstead, Stangl, and Arkowski LLCsDr. MJ Gonstead Dr. Melissa Stangl Dr. Lisa Arkowski Dr. Jennifer Gonstead

503 E. Clairemont Ave Eau Claire, WI 54701 (715) 832-2223