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Preble Chiropractic Office #1 * 102 W Madison Street * La Grange, KY 40031 * (502) 222-7611 * Fax: 866-516-1295 Preble Chiropractic Office #2 * 6540 Outer Loop * Louisville, KY 40228 * (502) 966-8281 * Fax: 866-536-6087

Confidential Patient Case History Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU

NAME __________________________________________________ DATE __________ HOMEPHONE ________ __

ADDRESS--------------------------- CITY ___________ STATE ______ ZIP ______ WORK PHONE ________ __

DATE OF BIRTH _ _ /_/_ AGE M 0 F 0 MARITAL STATUS NO. CHILDREN FAX# ________ _

OCCUPATION----------------------- SS# SPOUSE E-MAIL ____________ __

WHO IS RESPONSIBLE FOR THIS ACCOUNT? REFERRED BY

Please check the appropriate box for any of the following symptoms which you now have or have had previously. We want all the facts about your health before we accept your case. THIS IS A CONFIDENTIAL HEALTH REPORT.

0 - OCCASIONAL F - FREQUENT C - CONSTANT

0 F C GENERAL

0 0 DA!lergy 0 0 0 Chills 0 0 0 Convulsions 0 0 0 Dizziness 0 0 0 Fainting 0 0 0 Fatigue 0 0 0 Fever 0 0 0 Headache 0 0 0 Loss of sleep 0 0 0 Loss of weight 0 0 0 Nervousness/depression 0 0 0 Neuralgia 0 0 0 Numbness 0 0 0 Sweats 0 0 0 Tremors

MUSCLE & JOINT 0 0 0 Arthritis 0 0 0 Bursitis 0 0 0 Foot trouble 0 0 DHemia 0 0 0 Low back pain 0 0 0 Lumbago 0 0 0 Neck pain or stiffuess 0 0 0 Pain between shoulders

Pain or numbness in: 0 0 0 Shoulders 0 0 0 Arms 0 0 0 Elbows 0 0 0 Hands 0 0 0 Hips ODD Legs 0 0 0 Knees 0 0 0 Feet 0 0 0 Painful tail bone 0 0 0 Poor posture 0 0 0 Sciatica 0 0 0 Spinal curvature 0 0 0 Swollen joints

OFC GASTRO-INTESTINAL

0 0 0 Belching or gas 0 0 0 Colitis 0 0 0 Colon trouble 0 0 0 Constipation 0 0 0 Diarrhea 0 0 0 Difficult digestion 0 0 0 Distension of abdomen 0 0 0 Excessive hunger 0 0 0 Gall bladder trouble 0 0 0 Hemorrhoids 0 0 0 Intestinal worms 0 0 0 Jaundice 0 0 0 Liver trouble 0 0 0 Nausea 0 0 0 Pain over stomach 0 0 0 Poor appetite 0 0 0 Vomiting 0 0 0 Vomiting of blood

EYES, EARS, NOSE & THROAT

0 0 DAsthma 0 0 0 Colds 0 0 0 Crossed eyes 0 0 0 Deafuess 0 0 0 Dental decay 0 0 0 Earache 0 0 0 Ear discharge 0 0 0 Ear noises 0 0 0 Enlarged glands 0 0 0 Enlarged thyroid 0 0 0 Eye pain 0 0 0 Failing vision 0 0 0 Farsightedness 0 0 0 Gum trouble 0 0 0 Hay fever 0 0 0 Hoarseness 0 0 0 Nasal obstruction 0 0 0 Near sightedness 0 0 0 Nosebleeds 0 0 0 Sinus infection 0 0 0 Sore throat 0 0 0 Tonsillitis

OFC CARDIO-VASCULAR

0 0 0 Hardening of arteries 0 0 0 High blood pressure 0 0 0 Low blood pressure 0 0 0 Pain over heart 0 0 0 Poor circulation 0 0 0 Rapid heart beat 0 0 0 Slow heart beat 0 0 0 Swelling of ankles

RESPIRATORY 0 0 0 Chest pain 0 0 0 Chronic cough 0 0 0 Difficult breathing 0 0 0 Spitting up blood 0 0 0 Spitting up phlegm 0 0 0 Wheezing

SKIN 0 0 0 Boils 0 0 0 Bruise easily 0 0 0 Dryness 0 0 0 Hives or allergy 0 0 0 Itching 0 0 0 Skin eruptions (rash) 0 0 0 Varicose veins

GENITO-URINARY 0 0 0 Bed-wetting 0 0 0 Blood in urine 0 0 0 Frequent urination 0 0 0 Inability to control kidneys 0 0 0 Kidney infection or stones 0 0 0 Painful urination 0 0 0 Prostate trouble 0 0 0 Pus in urine

FOR WOMEN ONLY 0 0 0 Congested breasts 0 0 0 Cramps or backache 0 0 0 Excessive menstrual flow 0 0 0 Hot flashes 0 0 0 Irregular cycle 0 0 0 Menopausal symptoms 0 0 0 Painful menstruation 0 0 0 Vaginal discharge 0 Yes 0 No Are you pregnant?

CHECK THE FOLLOWING CONDITIONS YOU HAVE OR HAVE HAD: 0 Alcoholism 0 Anemia 0 Appendicitis 0 Arteriosclerosis 0 Arthritis 0 Cancer 0 Chorea

0 Cold sores 0 Diabetes 0 Diphtheria 0 Eczema 0 Emphysema 0 Epilepsy 0 Fever blisters

0 Goiter 0 Gout 0 Heart disease 0 HIV/AIDS 0 Influenza 0 Lumbago 0 Malaria

0 Measles 0 Miscarriage 0 Multiple sclerosis 0 Mumps 0 Pleurisy 0 Pneumonia OPolio

0 Rheumatic fever 0 Scarlet fever 0 Stroke 0 Tuberculosis 0 Typhoid fever 0 Ulcers 0 Venereal Disease 0 Whooping cough

Have you ever had previous chiropractic care?----------- If yes, date of last care-------- ----- ---- ----­

Do you have Health and Accident Insurance? If yes, with what company?------------------ --­

Is this an Industrial Accident Case? 0 Yes 0 No

#4327

....

PLEASE PRINT What is your major complaint?

Other complaints

How long have you had this condition? _ ______ Have you had this or similar conditions in the past? _ _______ _

What activities aggravate your condition?

ls this condition getting progressively worse? DYes DNo D Constant D Comes and goes

Is this condition interfering with your: DWork D Sleep D Daily routine D Other _ _ ______________________ _

How long bas it been since you really felt good?

List previous diagnoses and treatments you have received for pres ent condition------ ------- ---- --- --- - ------

What do you believe is wrong with you?

List surgical operations and years:

Drugs you now take: D Nerve pills D Pain killers D Muse le relaxers D "Pep" pills D Tranquilizers D Birth control pills

Others

Dental visits: D Every six months D Yearly D Toothache or emergency only D Complete dentures

Age of mattress: D Comfort able D Uncomfortable Do you use a bed board? ---------------­D Arch supports Are you wearing: D Heel lifts D Sole lifts D Inner soles

Have you been in an auto accident: D Past year D Past five years D Over five years D Never

Describe

Have you ever had any mental or emotional disorders? DYes DNo When? _____________ ________ _ ______ _

Have others in your family had such disorders? DYes D No When? ________________________ ____ ___

FAMILY HEALTH INFORMATION (Many health problems are t he result of hereditary spinal weaknesses; thus information about your family members will

give us a better picture of your total health picture.)

NAME

HAVE YOU EVER:

Been knocked unconscious?

Used a cane, crutch, or other support?

Been treated for a spine or nerve disorder?

Had a fractured bone?

Been hospitalized for other than surgery?

DO YOU:

Now take vitamins or minerals?

Think you may need vitamins or minerals?

Have an allergy to any drug?

DATE OF LAST:

Spinal examination

Physical examination

Blood test

Chest X-ray

Spinal X-ray

Dental X-ray

Urine test

HABITS Heavy

Alcohol D Coffee D Tobacco D Drugs D Exercise D Sleep D Appetite D

TION RELA

Less than 6 month s D D D D D D D

Moderate

D D D D D D D

Light

0 D D D D D 0

YES NO

D D D D D D D D D D

D D D D D D

6-18 months

D D D D D D D

None

D D D D D D D

IN CASE OF EMERGENCY: (Name of relative or close friend no t living in your home):

NAME

PAST AND PRESENT HEALTH PROBLEMS

DESCRIBE BRIEFLY

Over 18 months Never

D D D D D D

D D D D 0 D D D

LIST BELOW ALL CONDITIONS FOR WHICH YOU HAVE BEEN

TREATED IN THE PAST 10 YEARS.

ADDRESS __________________________ PHONE __________________________ _

Front BackDate: ____/____/____ Doc: LDP MEP Other _____

Acct No_____________

Name_____________________B.D.___/___/___

INS WC AUTOMCARE NOI

Diag. & Special Notes:

Preble Chiropractic Offices: Patient Progress RecordV

isit

#___

_

Chief complaint_____________________________________________________

How it happened____________________________________________________

Duration___________________________________________________________

Pain characteristic (sharp, dull, achy, numb, radiating, stiff, tingling, etc.)Pain intensity (intermittent, frequent, constant, etc.)Worse in AM or PMOverall progress since last visit (better, same, worse)

Mark the painful areasPain Scale ...1...2...3...4...5...

Mild SevereCircle pain scale number

Patient Initials:____________________

Ins PerCk Cash$__________Ck#________

NextAppt:

Rentals:

Vis

it #_

___

Activities of Daily Living Name Date File# Score ----------------------------- ---------~ ------------------------

Section 1-Pain Intensity 0 I have no pain at the moment 0 The pain is very mild at the moment 0 The pain is moderate at the moment o The pain is fairly severe at the moment 0 The pain is very severe at the moment o The pain is the worst imaginable at the moment

Section 2-Personal Care (Washing, Dressing, etc.) o I can look after myself normally without extra pain o I can look after myself normally but it causes extra pain o It is painful to look after myself and I am slow and careful o I need some help but manage most of my personal care o I need help every day in most aspects of self care 0 I do not get dressed. I was with difficulty and stay in bed

Section 3-Lifting o I can lift heavy weights without extra pain 0 I can lift heavy weights but it gives extra pain o Pain prevents me from lifting heavy weights off the floor,

I can manage if they are conveniently positioned o Pain prevents me from lifting heavy weights but I can

manage light to medium weights o I can lift only light weights 0 I cannot lift or carry anything at all

Section 4-Reading o I can read as much as I want with no pain in my neck 0 I can read as much as I want with slight pain in my neck o I can read as much as I want with moderate pain in my

neck 0 I can't read as much as I want due to moderate pain 0 I can hardly read at all because of severe pain 0 I cannot read at all

Section 5-Headaches 0 I have no headaches at all o I have slight headaches which come infrequently o I have moderate headaches which come infrequently o I have moderate headaches which come frequently 0 I have severe headaches which come frequently o I have headaches almost all the time

Section 6-Sitting ~"' . -

o I can sit in any chair as long as I like 0 I can only sit in my favorite chair as long as I like o Pain prevents me from sitting more than 1 hour o Pain prevents me from sitting more than Yz hour 0 Pain prevents me from sitting more than I 0 minutes o Pain prevents me from sitting at all

Section ?-Concentration 0 I can concentrate fully when I want to with no difficulty o I can concentrate fully when I want to with slight

difficulty 0 I have a fair degree of difficillty in concentrating o I have a lot of difficulty in concentrating when I want o I have a great deal of difficulty concentrating when I want o I cannot concentrate at all

Section 8-Work o I can do as much as I want 0 I can only do my usual work, but no more 0 I can do most of my usual work, but no more 0 I cannot do my usual work 0 I can hardly do any work at all o I can' t do any work at all

Section 9-Driving 0 I can drive my car without any neck pain 0 I can drive my car a long time with slight neck pain 0 I can drive my car a long time with moderate pain o I can't drive my car long due to moderate pain 0 I can hardly drive at all due to severe pain in my neck 0 I can't drive my car at all

Section tO-Sleeping 0 I have no trouble sleeping 0 My sleep is slightly disturbed (less than 1 hr. sleepless) o . My sleep is mildly disturbed (1-2 hrs. sJeepless) 0 My sleep is moderately disturbed (2-3 hrs. sleepless) o My sleep is greatly disturbed (3-5 hrs. sleepless) o My sleep is completely disturbed (5-7 hrs. sleepless)

Section 11-Recreation 0 I can perform all recreational activities with no pain 0 I can perform all recreational activities with some pain o I can perform in most recreational activities with pain o I can perform in few recreational activities due to pain o I can hardly do any recreational activities due to pain o I can't do any recreational activities at all

Section 12-Walking o Pain does not prevent me from walking any distance o Pain prevents me from walking more than I mile 0 Pain prevents me from walking more than Yz mile o Pain prevents me from walking more than ~ mile 0 I can only walk using a stick or crutches 0 I am in bed most of the time and have to crawl to the

toilet Section 13-Standing o I can stand as long as I want without extra pain 0 I can stand as long as I want but it gives me extra pain o Pain prevents me from standing for more than 1 hour 0 Pain prevents me from standing for more than Yz hour 0 Pain prevents me from standing for more than I 0 minutes 0 Pain prevents me from standing at .all

Section 14-Traveling o I can travel anywhere without extra pain 0 I can travel anywhere but it gives me extra pain 0 Pain is bad but I manage trips over two hours 0 Pain restricts me to trips ofless th"" one hour 0 Pain restricts me to trips under 30 minutes 0 Pain prevents me from traveling except to Doctor and

Hospital

ADVANCED NOTICE OF NON COVERAGE

In the event that my health insurance provider does not agree

to pay for any medical supply, equipment, care, etc. that Dr.

Preble has prescribed for the treatment of my condition, I do

hereby agree to take responsibility for payment and authorize

Preble Chiropractic Office to send me the appropriate invoice

for such charges.

Furthermore, for any outstanding balance that must go to

Collections, I am aware that there will be an additional fee of

40% added to my account balance to cover such services.

Date Signature

______ __________________________________________

AUTHORIZATION, ASSIGNMENT & RELEASE FORM

AUTHORIZATION AND ASSIGNMENT

In consideration of your undertaking to care for me, I agree to the following:

1. You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred.

2. I authorize the direct payment to you of any sum I now or hereafter owe you, by my attorney, out of the proceeds of any settlement of my case, and/or by any insurance company obligated to make payment to me or you based in whole or in part upon the charges made for your services.

3. In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data) and authorize you to prosecute said action in my name as you see fit and further authorize you to compromise, settle or otherwise resolve said claim as you see fit. However, it is understood that until a reasonable effort has been made to collect the sums due from the insurance company or companies contractually obligated, you will refrain from collecting the amounts owed, directly from me. I understand that whatever amounts you do not collect from insurance companies proceeds, whether it be all or part of what is due, I personally owe and agree to pay to you.

4. In addition to the above, I hereby waive the statute of limitations on collection and/or recovery in this State of Kmf!Jl:.ky .

5. I further agree that this Authorization and Assignment is irrevocable and ongoing until all monies owed are paid in full.

6. This Authorization for Assignment will be in continual effect until revoked by both parties.

Date Patient/Insured Signature

RECORDS RELEASE

To , I hereby authorize you to release to any information including the diagnosis and records of treatment or examination rendered to me for all care during the period from ___ _ to ____ _

Date Patient/Insured Signature

Date Staff Signature

RELEASE FROM CARE

I, hereby understand that Dr. is releasing me from care, for my accident dated , and that I have reached D a pre-accident status or D maximum medical improvement. I further understand that all expenses incurred from this accident are my responsibility or the insurance company's and that all expenses incurred after the date below will be my personal responsibility. I will make financial arrangements for payment directly.

Patient Signature Date Staff Signature

11130-228.()