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					PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center PERSONAL INFORMATION
Today's Date: ________________ File #:________________

First Name: _______________________________ Middle Initial: _____ Last Name: ______________________________________ Preferred First Name / Nickname: _________________________ Are you:  right handed  left handed  ambidextrous Social Security #:____________-______-____________ Date of Birth: _____/_____/_____ Age: __________

Address: ___________________________________________________________________________________________________ City: ______________________________________ State: _____________ Zip: _______________ Phone: ( Cell: ( ) __________-__________ Work: ( ) __________-__________ ) __________-__________ext.______ email:___________________________________ OK to call at work?  Yes  No

Occupation: ____________________________________ Employer: __________________________________________________ Business Address: ____________________________________________________________________________________________ Marital Status: S M D W Sex: M F Name of Spouse: ___________________________________________

Ages & Names of Children: ____________________________________________________________________________________ Who Referred You To Our Office Or How Did You Hear About Us? ___________________________________________________ Have You Had Previous Chiropractic Care?  No  Yes; if so please indicate when and the doctors name: __________________

__________________________________________________________________________________________________________ __________________________________________________________________________________________________________
 YES,  NO I authorize the following telephone numbers  YES,  NO I authorize the use of my address for mailing Home: ______________________Work ___________________________ Cell: _______________________ Pager: ___________________________ Indicate if you have a preferred mailing address: _____________________ Our office needs to leave messages, return telephone calls, and send office mail to your home address as part of our normal practice. Federal/State Health Insurance Portability and Accountability Act (HIPAA) patient privacy laws allow you to restrict doctor/staff communication with you or to contact you through alternative means. Please list telephone numbers that are acceptable for our office to call. Your agreement will allow our office to use your name and the indicated mailing address for sending reminders about scheduled appointments, re-activation letters, sending birthday/holiday cards, office newsletters, or providing information about other health related matters that may be of interest to you, billing statements/questions, status of your account, and other office related matters. We will use your home address, noted above, unless you indicate a preferred address. You may indicate a preferred mailing address by indicating so on this form. This authorization may be revoked by you at any time, by advising our office (Privacy Officer) of this revocation in writing. If you choose not to sign this authorization, this will not have any adverse effect on your treatment, eligibility for benefits, enrollment, or payment.

________________________________________
Signature: ____________________________Date:___________________ Expiration Date/Event for Authorization:  No expiration date When I have discontinued treatment and all bills have been paid.  Date: _______________________

IS THIS VISIT RELATED TO A:
 Work Related Injury/Symptoms  Sport or Recreational Injury  Motor Vehicle Crash Injury  Motorcycle-Bicycle Injury  Home Injury Symptoms  School/Employment Physical Non-Injury Pain/Symptoms  Check-up Only  Other (Describe):

HEALTH-MEDICAL INSURANCE INFORMATION
Does your insurance plan cover Chiropractic  Yes,  No If yes, we need a copy of the card treatment? If yes, indicate Insurance Company Name (Need Insurance Name: _____________________________ copy of card). Address: ____________________________________ Telephone: __________________________________ Are you the insured (wife/husband/child)? person or dependent  Insured,  Dependent

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PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center If you are the insured person’s dependent (spouse or Name of Insured Person: ___________________________ child), we need the insured person’s name, date of Social Security Number: ___________________________ birth, social security number, and the Insured Date of Birth: _____________________________ company/business name of the insured employer in Name of Insured Employer:_______________________ order to do billing. Amount: $ Percentage: % What is your co-payment amount for each visit?  Yes,  No Deductible $ ___________ Have you met deductible yet? Do you have a health insurance deductible for chiropractic? Specific chiropractic health insurance benefits Number visits per year #_____. Amount per year: $_______
Name, Address, Relationship, and Telephone Number of your nearest adult relative (for emergencies):

__________________________________________________________________________________________ _________________
OUR OFFICE WILL PROVIDE INSURANCE BILLING SERVICES FOR AS A COURTESY. HOWEVER, IN ORDER TO KEEP OUR OFFICE OVERHEAD DOWN AND KEEP OUR PATIENT FEES REASONABLE, WE EXPECT PAYMENT AT THE CONCLUSION OF EACH TREATMENT FOR CASH PATIENTS AND THE CO-PAYMENT AND/OR DEDUCTIBLE FOR REGULAR HEALTH INSURANCE PATIENTS. Patient Signature and Date

I am a responsible party and agree to pay for any outstanding bills incurred in this office. It is my responsibility to pay any deductible, co-insurance, and/or any other balances not paid by my health/automobile insurance carrier. Minors must have parent’s signature.

Date of Your Last Physical Examination: _____/_____/_____

CURRENT COMPLAINTS
Pain Drawing: Please mark where and what type of pain you are currently experiencing. Use the symbols indicated to describe the type of pain or sensations you are feeling:

Use these symbols to describe the type of pain or sensations you are feeling: >>> /// Aching pain Stabbing or Sharp pain

XXX Burning pain === ooo Numbness Pins and Needles

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PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center
Please list your complaints below with the most significant or primary complaint first: 1. Area of Pain: ________________________________ Frequency:  intermittent  occasional  frequent  constant Please circle the number which best describes the severity of your pain; 1 = no pain & 10 is unbearable pain: No Pain 1 2 3 4 5 6 7 8 9 10 Unbearable Pain

The pain is aggravated by: ______________________________________________________________________________ The pain is relieved by: ________________________________________________________________________________ 2. Area of Pain: ________________________________ Frequency:  intermittent  occasional  frequent  constant Please circle the number which best describes the severity of your pain; 1 = no pain & 10 is unbearable pain: No Pain 1 2 3 4 5 6 7 8 9 10 Unbearable Pain

The pain is aggravated by: ______________________________________________________________________________ The pain is relieved by: ________________________________________________________________________________ 3. Area of Pain: ________________________________ Frequency:  intermittent  occasional  frequent  constant Please circle the number which best describes the severity of your pain; 1 = no pain & 10 is unbearable pain: No Pain 1 2 3 4 5 6 7 8 9 10 Unbearable Pain

The pain is aggravated by: ______________________________________________________________________________ The pain is relieved by: ________________________________________________________________________________ 4. Other: ___________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ In general my symptoms are worse in:  AM  Midday  PM;  my symptoms do not change with the time of day. Are your symptoms / condition:  improving  unchanged  getting worse

HISTORY
Symptoms developed from:  work injury  car accident  sports injury  lifting/fall  gradual  unknown The pain began on or about: ______________________. The pain is chronic and originally began on or about: _________________ Describe how the symptoms began or what you think caused the symptoms / condition: _____________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ List other doctors you have seen for this complaint, the type of treatment given, and the result of that treatment: __________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Describe any past history of the same or similar complaint: ____________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Page 3 of 8

PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center

MEDICAL HISTORY
CHECK HERE IF YOU HAVE HAD OR ARE EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS:  Blurring vision  Buzzing or ringing in ears  Dizziness  Numbness  Loss of bowel or  Confusion bladder function  Loss of sleep  Constipation  Stomach difficulty  Diarrhea  Frequent urination  Rectal bleeding  Frequent colds  Allergies  Asthma Do you have a pacemaker?  Yes  No  Headaches: Area of head:___________________ How often:  daily  ____ times per day  ____ times per week  ____ times per month     Chest pains Painful urination Difficulty swallowing Hay fever

Please list any serious illness or medical conditions you have had and associated treatment: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Please list the name and address of your primary care physician & any specialist you have seen: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

SURGICAL HISTORY
Please list any surgeries you have had; include date, type of surgery or for what condition and outcome: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

FAMILY HISTORY
Please list any family history of heart disease, cancer, diabetes or other serious illness: ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Women Only Important - if you suspect you are currently pregnant, please notify the doctor immediately. X-rays should not be taken if you are pregnant!
Are you pregnant?  Yes  No No Page 4 of 8 Date of last menstrual cycle: ________________________ Do you have PMS?  Yes 

PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center

WORK HISTORY
How many hours do you normally work in a week? _____________ Are you currently not working?  Yes  No In a typical workday, I: (circle the number of hours per day per activity) Sit 1 2 3 4 Stand: 1 2 3 4 Walk 1 2 3 4 On the job, I perform the following activities: 5 5 5 6 6 6 7 7 7 8 8 8 hours hours hours

In terms of an 8-hour workday, "occasionally" = 33%, "frequently" = 34% to 66%, and "continuously" = 67% to 100% of the day. Not At All Bend / Stoop  Squat  Crawl  Climb  Reach above shoulder level  Crouch  Kneel  Balancing  Pushing / Pulling  Check the category that best describes your work:      Occasionally          Frequently          Continuously         

Sedentary: Lifting up to 10 lbs. maximum and occasionally lifting and / or carrying such articles as dockets, ledgers, and small tools.
Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking is required only occasionally and other sedentary criteria are met. Light Work: Lifting 20 lbs. maximum with frequent lifting and / or carrying of objects weighing up to 10 lbs. Even though the weight lifting may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling or arm and / or leg controls. Medium Work: Lifting 50 lbs. maximum with frequent lifting and / or carrying of objects weighing up to 25 lbs. Heavy Work: Lifting 100 lbs. maximum with frequent lifting and / or carrying of objects weighing up to 50 lbs. Very Heavy Work: Lifting objects in excess of 100 lbs. with frequent lifting and / or carrying of objects weighing 50 lbs. or more.

SOCIAL HISTORY
Do you smoke?  N o  Yes; if yes, how many packs of cigarettes do you smoke per day? ____________________ How many cups of coffee or caffeinated drinks do you have per day? __________ Do you consume alcohol?  No  Yes; if yes, would you say that your use of alcohol is  occasional  frequent or  daily. Would you say your consumption of alcohol is  light,  medium, or  heavy? Do you have a regular program of exercise?  No  Yes, if yes, please note the frequency and type of exercise that you do: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ List any hobbies or recreational sports / activities you enjoy doing: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

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PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center Fill This Section Out If Your Injury Is Related To an Automobile Accident
Date of accident: ______________________ Hour: _____________  AM  PM Were you the  driver  passenger:  front seat  back seat;  pedestrian. Were you struck from  behind  driver's side  passenger's side  head on. Were the roads  dry  wet  snowy. Were you wearing a seat belt  Yes  No

Do you recall any part of your head or body striking any part of the interior of the car?  Yes  No If yes, please describe: ________________________________________________________________________________________ ___________________________________________________________________________________________________________ Type of vehicle you were in? _____________________________ Type of vehicle that struck you? ____________________________ Head / body position at time of impact:  head turned to left / right  body straight in sitting position Were you knocked unconscious?  Yes  No.  head looking back  body rotated to left / right  head straight forward  other:____________________________

Did you feel pain  immediately  gradually  next day  other: _________________________________________________ Did you receive first aid?  Yes  No Did you go to the hospital by  ambulance,  a friend, or did you  drive yourself. Name of hospital: ____________________________________________________________________________________________ Did the hospital take x-rays?  Yes  No. What treatment was given? ______________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Have you been unable to work because of the accident?  No  Yes; if yes since when: _____/_____/_____ Have you consulted an attorney?  No  Yes; if yes please give name, address, and phone: ________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Fill This Section Out If Your Injury Is Related To a Work Accident
Date of accident: _____/_____/_____ Hour: _____________  AM  PM Did you report the accident to your supervisor within 48 hours?  Yes  No Did a fellow employee witness the accident?  Yes  No Have you been unable to work because of the accident?  No  Yes; if yes since when: _____/_____/_____ Have you consulted an attorney?  No  Yes; if yes please give name, address, and phone: ________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Patient’s Signature: _____________________________________________ Date: _____/_____/_____ (or guardian if child)

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PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center
HIPAA Notice of Privacy Practices

HIPAA NOTICE OF PRIVACY PRACTICES This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This Notice of Privacy Practices describes how we may use and disclose our protected health information (PHI) to carry out treatment, payment or health care operations (TPO) for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that my identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION • TREATMENT: We will use and disclose Your Protected Health Information to make decisions about the provision, coordination, or management of you healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share Your Protected Health Information with another healthcare provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of health information for treatment purposes that may or may not be necessary in your case. • PAYMENT: We will use and disclose Your Protected Health Information to obtain reimbursement from you, for you health insurance carrier, or from another insurer for our services rendered to you. This may included determinations of eligibility or coverage under the appropriate health plan, pre certification and preauthorization of services, or review of services for the purpose or reimbursement. Your Protected Health Information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system. • HEALTHCARE OPERATIONS: We may disclose, as needed, Your Protected Health Information in order to support the business activities of your physician’s practice. These activities include, but are not limited to providing appointment reminders, newsletters and holiday, birthday and thank you communication. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose Your Protected Health Information in the following situations without your authorization. These situations include: as required by law, Public Health Issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donations. Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164,500. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES: Will be made only with your consent, authorization or opportunity to object as required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

________________________________ ______________________ Signature or Patient/Personal Representative Date

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PATIENT HEALTH QUESTIONNAIRE Dr. Shara Posner/ Back To Health Center

INFORMED CONSENT
I hereby consent to the performance of chiropractic adjustments and other chiropractic procedures, on myself, (or on the patient named below, for whom I am legally responsible) by Shara Posner, MS DC, and/or other licensed doctors of chiropractic who now or in the future provide chiropractic adjustments and other types of treatment for me. This consent includes other doctors of chiropractic that are employed by, associated with, or serve as back-up for Shara Posner,MS DC, whether or not their names are listed on this form. I understand and consent to the following procedures: examination, x-rays (if needed), neck and spine/extremity adjustments, joint mobilization, electrical therapies, traction, and/or other procedures recommended for my condition(s). I have had an opportunity to discuss with Shara Posner MS DC, the various types of treatment, including spinal adjustments, that have been proposed to me for my condition, and the purpose and objectives of these chiropractic procedures. I understand that the results from the chiropractic treatment are not guaranteed for my condition. I have been informed about the risks and benefits of chiropractic adjustments and other chiropractic procedures, and understand that, there are some uncommon potential serious risks to chiropractic adjustments and procedures, including, but not limited to, sprains, fractures, disc injuries, dislocations, nerve injuries, and strokes specifically from neck adjustments. I understand and have had the opportunity to ask about risks and benefits the proposed treatment and of other alternative types of treatment for my condition. I have had the opportunity to read this form understand the above statements, accept the risks mentioned, and hereby consent and agree to chiropractic treatment over the entire course of treatment for my present condition and any future conditions for which I seek treatment.

PATIENT NAME (PRINT): __________________________________DATE: ____________
X____________________________________________________________________________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY
NAME: ___________________________________ RELATIONSHIP: ____________________
Indicate your name and relationship (parent/guardian/personal representative) if signing for patient (minor):

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