Peter M · Web viewLow back pain Neck pain Fatigue Osteoporosis Mid back pain Headaches Diabetes Arthritis Shoulder pain Elbow pain Thyroid disorder Cancer Hand/wrist pain Hip pain

Print Patients Name: Date:

Signature:______________________________________________

Date of Birth: _____ Age:__________

Address: Social Security #:

City: State: Zip Code:

Home Phone: Cell Phone: Email: _________________

Emergency Contact: Name Telephone:

Occupation:

Which one of our patient’s recommended you to our office?

List the main problem(s) you are having or the purpose for your consultation:□ Low back pain □ Neck pain □ Fatigue □ Osteoporosis

□ Mid back pain □ Headaches □ Diabetes □ Arthritis

□ Shoulder pain □ Elbow pain □ Thyroid disorder □ Cancer

□ Hand/wrist pain □ Hip pain □ High blood pressure □ Acid reflux

□ Knee pain □ Foot/ankle pain □ High Cholesterol □ Other

Please elaborate on your condition below:

How long ago did your symptoms begin?

What types of treatments have you received for your condition? ________________________________________________________________________

Have any of these treatments been helpful and if so which ones? ________________________________________________________________________________________________________________________________________________What makes your symptoms worse (i.e. certain movements, weather changes, etc)? ________________________________________________________________________

1Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214

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Please describe your pain symptoms:Achy □ Sharp □ Dull □ Burning □ Tight □ Numb □ Stiff □Throbbing □ Shooting □ Stinging □ Stabbing □ Other □How often do your symptoms occur?Constant (all the time) □ Frequent □ Intermittent □Is it worse in the: A.M. □ P.M. □ After activity □ With movement □Other □Please describe: ________________________________________________________________________________________________________________________________________________

Please use the diagram below to demonstrate the location of your pain:

Rate the severity of your pain: No pain 0-1-2-3-4-5-6-7-8-9-10 Severe Pain

Rate your overall health: Poor 0-1-2-3-4-5-6-7-8-9-10 Excellent

Rate your energy levels: Poor 0-1-2-3-4-5-6-7-8-9-10 Excellent

If you could make only one improvement in your health, what would it be?

_______________________________

2Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214

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Symptom Questionnaire: The following questions have been developed to help evaluate your health needs. This process is only as accurate as the information that you provide. If you feel that the topics below do not allow you to verbally express your problem(s), please elaborate during our personal consultation. I would like to remind you that all of this information is strictly confidential unless you state otherwise. If Yes or No does not apply to you then elaborate in the margin.

1. We re y ou b re a stf e d a s a b a b y ? I f y e s how lo n g ? Yes No 2. W e re y ou d e liv e r e d via c e s a re a n se c tion? Y e s No 3. H a ve y ou b e e n thro u g h a n y str e s s ful situ a tions r e c e nt l y ? Y e s No 4. Do y ou c onsid e r y our s e lf to be a p e rson w ho is e a si l y s t r e ssed out? Y e s No 5. Do y ou n ee d g lass e s to r ea d? Y e s No 6. Do y ou n ee d g lass e s to s e e thin g s a t a dist a n c e ? Y e s No 7. Do y ou e v e r h a ve p a in or pr e ssure in y our e y e s? Y e s No 8. A r e y our e y e s o ft e n r e d o r in f lam e d? Y e s No 9. Do y o u r e y e s o r f a c e of te n a pp ea r p u f f y ? Y e s No 10. Do y o u r e y e lids c o nstan tl y twit c h? Y e s No 11. A r e y our e y e s oft e n d r y a nd it c h y ? Y e s No 12. Do y ou o ft e n h a v e d a rk c ir c les und e r y o u r e y e s? Y e s No 13. Do y ou h a ve to w e a r su n g lass e s wh e n outside? Y e s No 14. Do y ou find it dif f icu l t to drive a t ni g ht? Y e s No 15. Do y ou h a ve trouble s ee i ng c l ea r l y in d a rk li g hti n g ? Y e s No 16. A r e y our mouth, e y e s, or thro a t ch r oni c a l l y d r y ? Y e s No 17. Do y ou f r e q u e nt l y h a ve a sour or met a llic t a ste in y o ur mouth? Y e s No 18. Do y ou h a ve to w e a r lip b a lm r e g ula r l y to k e e p y our lips f r om ch a ppi n g ? Y e s No 19. Do y o u r lips c r a c k a nd b l ee d on a re g ular b a sis? Y e s No 20. Do f e v e r bliste r s or c a n k e r so r e s o ft e n bother y o u ? Y e s No 21. A r e y ou troubl e d b y bl ee ding g ums? Y e s No 22. H a ve y ou lost a n y of y o u r a dult te e th? Y e s No 23. Do y ou h a ve a h i sto r y o f d e ntal ca r i e s (c a vities ) ? Y e s No 24. H a ve y ou o f t e n h a d se v e r e tooth ac h e s? Y e s No 25. Do y ou h a ve a n y d e ntal i mpl a nt s ? Y e s No 26. Do y ou h a ve a n y m e tal f i llin g s? Y e s No 27. I s y o u r ton g u e usu a l l y b a d l y c o a ted? Y e s No 28. Do y ou h a ve c h ronic h a l i tosis (b a d br e a th)? Y e s No 29. H a ve y ou e v e r had fluids l ea king f r om y our e a r? Y e s No 30. Do y ou w e a r a h e a ri n g a i d ? Y e s No 31. Do y ou h a ve c ons t a nt rin g i n g or n o ises in y our ea r ? Y e s No 32. Do y ou g e t di z z y on a re g ular b a sis? Y e s No 33. Do y ou h a ve to cl e a r y o u r th r o a t constant l y ? Y e s No 34. H a ve y ou h a d y o u r tonsils r e moved? Y e s No 35. A r e y ou o f ten t roubl e d w ith sp e lls of sn e e z ing or all e r g ies? Y e s No 36. I s y o u r nose c ontinu a l l y stuff e d up? Y e s No 37. A r e y ou s e nsitive to f u m e s, smok e , p e r f u m e s, or other c h e mi c a l odors? Y e s No

3Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214 www.blueashchiro.com

38. Do y ou o ft e n find it dif f i c ult to br e a the out of y o u r nose? Y e s No 39. Do y ou su f f e r f r om a c o n stant l y r unni n g nos e ? Y e s No 40. H a ve y ou a t tim e s had b a d nos e ble e ds? Y e s No 41. Do y ou e v e r h a ve spont a n e ous nosebl ee ds? Y e s No 42. H a ve y ou noti ce d a n y c h a ng e s in y our a bili t y to t a ste or smell re c e nt l y ? Y e s No 43. Do y ou su f f e r f r om ast h ma or a n y other c h r onic l ung dise a s e ? Y e s No 44. A r e y ou troubl e d b y c on s tant c ou g hi n g? Y e s No 45. Do y ou g e t si c k more th a n twice p e r y e ar? Y e s No 46. H a ve y ou ta k e n a ntibiotics re c e nt l y ? Yes No 47. H a ve y ou e v e r had to t a ke a ntibiotics more th a n o n c e f or a c h r on i c a ilmen t ? Y e s No 48. Do y ou su f f e r f r om f r e q u e nt or s e v e r e h ea d ac h e s? Y e s No 49. Do y ou o ft e n h a v e sinus c ong e stion? Y es No 50. I s y o u r a pp e tite a l w a y s p oor? Y e s No 51. Do y ou us u a l l y ea t sw e e ts or other f oods b e t w ee n me a ls? Y e s No 52. Do y ou a lw a y s g ulp y our f ood hu r ri e d l y ? Y e s No 53. Do y ou o ft e n suff e r from a n ups e t stoma c h? Y e s No 54. Do y ou us u a l l y f ee l blo a t e d a fter e a ti n g ? Y e s No 55. Do y ou us u a l l y b e lch a l ot a f ter e a tin g ? Y e s No 56. A r e y ou o f ten s i c k to y o u r stoma c h? Y e s No 57. Do y ou e v e r s u f f e r f rom indi g e stion? Y e s No 58. Do y ou o ft e n take med i c a tion f o r h e a rtbu r n? Y e s No 59. H a ve y ou e v e r be e n di a gnos e d with stom ac h ulc e r s ? Y e s No 60. Do y ou su f f e r f r om f r e q u e nt loose bow e l mov e m e nt s ? Y e s No 61. Do you experience abdominal pain shortly after bowel movements? Y e s No 62. Do y ou h a ve a t l e a st one bow e l mov e ment p e r d a y ? Y e s No 63. Do y ou e v e r e x p e ri e n c e a bur n ing or it c hi n g sen s a t ion in the a nu s ? Y e s No 64. H a ve y ou e v e r had se v er e bloo d y di a r r h e a ? Y e s No 65. Do you have foul smelling gas frequently? Y e s No 66. Do you have gas frequently? Y e s No 67. I s the c olor of y o u r stool oft e n tan? Y e s No 68. I s the c olor of y o u r stool ev e r dark bl a c k? Y e s No 69. W e re y ou e v e r t r oubled with intestin a l wo r ms or p a r a sit e s? Y e s No 70. Do y ou c onst a nt l y s u f f e r f r om constip a tio n ? Y e s No 71. H a ve y ou e v e r had pil e s ( r ec t a l hemo r rhoids ) ? Y e s No 72. H a ve y ou tr a v e led out of the c ount r y r e ce nt l y ? Y e s No 73. H a ve y ou e v e r had jaun d ice ( y e llow e y e s a nd ski n )? Y e s No 74. H a ve y ou e v e r had se r io u s liv e r or g a ll bladd e r t r o uble? Y e s No 75. Do y ou find it dif f icult to g e t to sl ee p a t ni g ht? Y e s No 76. Do y ou h a ve dif f i c ul t y re memb e r ing d re a ms f r om the ni g ht be f o re? Y e s No 77. A r e y ou bother e d b y n i ghtm a r e s? Y e s No 78. Do y ou find it impossible to t a ke a r e g u l a r r e st pe r i od eac h d a y ? Y e s No 79. A r e y ou e x h a usted upon w a king i n the mo r ni n g ? Y e s No 80. Do y ou n ee d c o f f e e to w a ke up a nd h a ve e n e r g y in the mo r nin g ? Y e s No 81. A r e y ou o f ten e x h a usted or fa t i g u e d? Y e s No 82. Do y ou sl e e p less than 8 hours a d a y ? Y e s No 83. Do e s eve r y little e f f o r t w ea r y ou out? Y e s No

4Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214 www.blueashchiro.com

84. Do e s ne r vous e x h a ustion r un in y our f a mi l y ? Y e s No 85. A re y ou f r e qu e nt l y c o n fin e d to bed b y illness? Y e s No 86. A r e y ou a l w a y s in poor h ea lth? Y e s No 87. A r e y ou c onsid e r e d a si c k l y p e rson? Y e s No 88. Did y ou e v e r h a ve s c a rl e t fe v e r? Y e s No

89. Did y ou e v e r h a ve mal a ri a ? Y e s No 90. W e re y ou e v e r t rea t e d f o r s e v e r e a n e mi a ? Y e s No 91. W e re y ou e v e r t rea t e d f o r v e n e r ea l dis ea s e ? Y e s No 92. Do y ou h a ve dia b e tes? Y e s No 93. Did a do c tor e v e r s a y y o u h a d a g oit e r in y our n e c k ? Y e s No 94. Did a do c tor e v e r t r e a t y ou f o r a tumor or ca n c e r? Y e s No 95. Do y ou su f f e r f r om a n y c h r onic dis ea s e ? Y e s No 96. Did y ou e v e r h a ve a s e r i ous o p e r a tion? Y e s No 97. Did y ou e v e r h a ve a s e r i ous inju r y ? Y e s No 98. Do your muscles and joints constantly feel stiff? Yes No 100 . H a ve y ou e v e r be e n told that y ou h a d a rth r itis? Y e s No 101 . Do p a ins in the b a c k ma k e it h a rd for y ou to k e e p up with y our w o rk? Y e s No 102 . Do mus c le c r a mps or spasms f r e qu e nt l y bother y o u ? Y e s No 103 . Do y ou h a ve numbness o r tin g ling in a n y p a rt of y our b o d y ? Y e s No 104 . Do y o u r fe e t ev e r fe e l li k e th e y bur n ? Y e s No 105 . H a ve y ou e v e r had a seizu r e or c onvulsion? Y e s No 106 . H a s a d oc tor e v e r s a id y o ur blood pr e ssure w a s t o o hi g h? Y e s No 107 . H a s a d oc tor e v e r s a id y o ur blood pr e ssure w a s t o o lo w ? Y e s No 108 . Do y ou h a ve p a ins in the h ea rt or c h e st? Y e s No 109 . A r e y ou o f ten bot h e r e d b y thumping o f the h e a rt? Y e s No 110 . Do e s y our h e a rt o f ten r a c e like mad? Y e s No 111 . Do y ou o ft e n h a v e dif f i c ul t y with br e a thi n g ? Y e s No 112 . Do y ou run o ut of b r e a th ea si l y ? Y e s No 113 . Do y ou som e times g e t o u t of b rea th just sitting stil l ? Y e s No 114 . A r e y our a nkles o f ten ba d l y swoll e n? Y e s No 115 . Do c old hands or f ee t tr o uble y ou, e v e n in hot we a the r ? Y e s No 116 . Do y ou su f f e r f r om f r e q u e nt c r amps in y our le g s? Y e s No 117 . H a s a d oc tor e v e r s a id y o u h a d h ea rt troub l e ? Y e s No 118 . Do heart trouble r un in y our f a mi l y ? Y e s No 119 . H a s y our c holes t e rol e v e r b e e n h i g h? Y e s No 120 . Do y ou g e t up eve r y ni g h t to urin a te? Y e s No 121 . Du r ing t h e d a y , do y ou u sual l y h a v e to urin a te frequ e nt l y ? Y e s No 122 . Do y ou o ft e n h a v e severe bur n ing w h e n y ou u r ina t e ? Y e s No 123 . Do y ou som e times lose control of y o u r bl a dd e r? Y e s No 124 . H a s a d oc tor e v e r s a id y o u h a d kidn e y or bl a dd e r dise a se Y e s No 125 . I s y o u r m e mo r y poo r ? Y e s No 126 . Do y ou h a ve dif f i c ul t y re memb e ring d a i l y t a sks or rece nt e v e nts? Y e s No 127 . Do y o u r thou g hts s e e m f og g y or c lou d y ? Y e s No 128 . Do y ou find it dif f icult to fo c us or c o n ce nt r a te on d a i l y a c tivitie s ? Y e s No 129 . H a ve y ou e v e r be e n und e r the c a re of a p s y c hiatri s t ? Y e s No 130 . Do e s wo r r y i n g c ontinu a lly g e t y ou down? Y e s No

5Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214 www.blueashchiro.com

131 . Do y ou f e e l alo n e a nd s a d a t a p a r t y ? Y e s No 132 . Do y ou us u a l l y f ee l unh a p p y or d e p re s s e d? Y e s No 133 . Do y ou o ft e n c r y ? Y e s No 134 . H a ve y ou e v e r h a d a n er vous br e a kdown? Ye s No 135 . Do y ou a lw a y s do thi n g s on sudden impuls e ? Y e s No 136 . A r e y ou e a si l y up s e t or i r ritat e d? Y e s No 137 . Do little a nn o y a n c e g e t on y our n e rv e s a nd g e t y o u a ng r y ? Y e s No 138 . Do p e ople o f ten a nn o y a nd ir r it a te y ou? Y e s No 139 . Do y ou o ft e n sh a ke o r t r e mbl e ? Y e s No 140 . A r e y ou c onst a nt l y k e y e d up or jitt e r y ? Y e s No 141 . D o sudd e n nois e s make y ou jump or sh a k e ? Y e s No 142 . Do y ou t r e mble or f ee l w ea k wh e n e v e r so m e one s houts a t y ou? Y e s No 143 . Do f r i g hteni n g thou g hts k ee p c omi n g b a c k in y o u r min d ? Y e s No 144 . Do y ou o ft e n b e c ome f r i g hte n e d for no a pp a r e nt r ea son? Y e s No 145 . Do y ou o ft e n bre a k out in a c old sw ea t? Y e s No 146 . Do e s life look entir e l y h o p e less? Y e s No 147 . Do y ou o ft e n wish y ou w e re d e a d a nd a w a y f r om it al l ? Y e s No 148 . Do y ou b ruise ea si l y ? Y e s No 149 . Do e s it take longer than 10 d a y s for a c ut or b r ui s e to he a l? Y e s No 150 . I s ac ne c onst a nt l y a pro b l e m? Y e s No 151 . I s y o u r skin c onst a nt l y b r ok e n out with bump s ? Y e s No 152 . Do y ou h a ve to w e a r lotion to ke e p y our skin f r o m d r y i n g out? Y e s No 153 . Do y ou b r e a k out in r a s h e s on a r e g u l a r b a sis? Y e s No 154 . I s y o u r h a ir d r y a nd b r ittl e ? Y e s No 155 . Did y our h a ir turn g r a y p r e matu re l y ? Y e s No 156 . A r e y our fing e r n a ils w e a k or r idged? Y e s No 157 . Do y ou h a ve f ood c r a vi n g s? Y e s No 158 . Do y ou c r a v e ic e ? Y e s No 159 . A r e y ou hu n g r y short l y a ft e r a m e a l? Y e s No 160 . Do y ou ea t out a t r e s t a u r a nts f re qu e nt l y ? Y e s No 161 . Do y ou c onsume fa st fo o d oft e n? (more than 2 x weekly) Y e s No 162 . Do y ou d rink soda on a d a i l y b a sis? (daily) Y e s No 163 . Do y ou h a ve a histo r y o f s e x u a l promis c ui t y with multiple p a rtn e rs? Y e s No 164 . H a ve y ou e v e r be e n di a gnos e d with a s e x u a l l y transmitt e d dise a s e ? Y e s No 165 . H a ve y ou e v e r be e n a s u bstan c e a bu s e r? Y e s No 166 . H a ve y ou e v e r a b used a l c ohol? Y e s No 167 . Do y ou d rink a lcohol on a d a i l y b a sis? Y e s No 168 . Do y ou d rink c o f f e e on a d a i l y b a sis? Y e s No 169 . Do ce rt a in foods m a ke y ou f e e l ill? (c o r n, wh e a t, dai r y ) Y e s No 170 . Do y ou smoke o r use a n y toba c c o pr o d u c ts? Y e s No 171 . A r e y ou c onst a nt l y e x posed to se c ond h a nd smok e ? Y e s No 172 . Do y ou c onsid e r y our s e lf to be ov e r w e i g ht? Y e s No 173 . Do y ou c onsume less th a n 5 s e rvin g s o f f ruits and v e g e tabl e s p e r d a y ? Y e s No 174 . Do y ou e x e r c ise 5 times p e r w e e k or mo re ? Y e s No 175 . Do e s f a t i g ue k ee p y ou fr om e x e r c isin g ? Y e s No 176 . I s y o u r w a t e r int a ke less than 64 oun c e s (8 c ups) p e r d a y ? Y e s No

6Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214 www.blueashchiro.com

Please fill in any other symptoms not asked about, please elaborate below:

7Sycamore Chiropractic and Nutrition 9500 Kenwood Rd Blue Ash OH 45242 (513)773-1214 www.blueashchiro.com

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Past Medical History: please indicate below any health problems you have experienced in the past.

Major Illnesses (Please list dates when conditions were diagnosed):

Accidents or Major Trauma (Please list dates. For scars please give locations):

Surgeries/Hospitalizations (Please list dates):[ ] Colostomy [ ] Esophageal [ ] Cholecystectomy[ ] Gastric [ ] Ileostomy [ ] Nephrectomy[ ] Hemorrhoidectomy [ ] Tonsillectomy [ ] Appendectomy[ ] Bowel (intestinal) [ ] Vasectomy [ ] Hysterectomy (partial or complete)[ ] Other

Dental Procedures (Root canals, total number of cavities, etc):

Allergies and/or Sensitivities (Drugs, chemicals, foods, environmental):

Occupational Exposures (i.e. mercury, asbestos, etc):

Lifestyle - Check those that apply to you:[ ] Alcohol ( daily weekly monthly) [ ] Exercise ( none daily weekly monthly )[ ] Housebound [ ] Smoker ( packs/day)[ ] Soft drink consumption ( /day) [ ] Coffee consumption ( cups/day)[ ] Sedentary Job [ ] Fast food consumption (daily weekly monthly)[ ] Sexually active [ ] Married (yes no divorced)

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Women Only: Last Pap- Date of Last menstrual period- Marital History: Years married- # of children- Ages- # of Pregnancies- Deliveries- Complications- Use of Contraceptives? What type? Currently menstruating?

Abnormal Pap (HPV, CIN, etc.)?

If yes check any of the following symptoms you experience around your periods:[ ] Heavy bleeding [ ] Painful cramping [ ] Intense mood swings [ ] Bloating [ ] Food Cravings (sweets, chocolate, etc.) [ ] Headaches [ ] Irregularly timed cycles [ ] Extreme fatigue [ ] Anxiety [ ] Depression [ ] Breast tendernessIf peri/post-menopausal check any symptoms that you are currently experiencing:[ ] Hot/cold flashes [ ] Vaginal dryness [ ] Hair loss [ ] Dry skin

Men Only: Date of last prostate exam-Abnormal Prostate findings?- Marital History: Years married- # of children- Rate your job stress (0-10)-

Nutritional (diseases, diet, food habit, etc):[ ] Anorexia [ ] Bulimia [ ] Carbohydrate Loading[ ] Fasting (chronic) [ ] Fiber Intake (high) [ ] Food Addictive Intake (high)[ ] Lactose Intolerance [ ] Oxalate Intake (high) [ ] Phytate Intake (high)[ ] Malnutrition [ ] Protein Intake (high) [ ] PUFA Intake (high)[ ] Salt Intake (high) [ ] Saturated Fat Intake (high) [ ] Tannic Acid Intake (high)[ ] Vegetarian Diet [ ] Vegan Diet [ ] Weight Loss (involuntary)[ ] Atkins Diet [ ] Hollywood Diet [ ] South Beach Diet

[ ] Other diet : Please list and describe below.

Nutritional Supplements – Please use the chart below to list all vitamins, minerals, amino acids, or other supplemental products (meal replacement drinks bars, etc.) you are currently taking.

Supplements Brand Form Dose/Frequency Length of Time

For Example:Vitamin E Nature’s Made Soft gel cap 400 IU/1 X Day 6 Months

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Medications – Please list all medications (prescription and over the counter) you are currently taking

Length of time Dose FrequencyFor Example:Ibuprofen OTC 1 week 400 mg 2 X day

24-Hour Diet Recall: Please list all the foods and beverages you have consumed in the past 24 hours.

BREAKFAST:

LUNCH:

DINNER:

SNACKS:

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Family Medical History:Please give age, lists of any illness, or if deceased.If dec e a sed, l ist c a u s e of d e ath a nd a ge o f death.

Children:

Mother:

Father:

E x a m ple s : Arthritis-Type Genetic Disease - Type Celiac Disease Alzheimer’sAllergies AlcoholismAsthmaBleeding Tendency Cancer-Type Crohn’s DiseaseDiabetes-Age at Onset Drug AbuseEpilepsy

Brothers and Sisters: Gall BladderGlaucomaHeart Disease-Type High Blood Pressure Hearing Loss Hypoglycemia Kidney Disease Liver Disease-Type

Mother’s Parents: OsteoporosisLupusMental Illness- Type Multiple Sclerosis Rheumatoid Arthritis Thyroid Disease TuberculosisSkin Disease-Type

Father’s Parents: Other Conditions

Genetic Ethnic Background/Ancestry (i.e. Irish, Scottish, Middle Eastern, etc.):

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** Very Important Information **

Please Read Carefully and Sign After Reading.

Payment Requirements: Payment for all services is expected at the time of appointment. Visa, MasterCard, check, cash, or Traveler’s checks are accepted. The clinic is now offering a service called Credit Care to help with your financial needs. Please ask for more details at the check out desk.

Appointments: Please kindly give more that 24 hours notice if you must change or cancel your appointment. We c ha r ge a $ 75 f e e f or m iss e d appoi n t m e nts or if less than 24 h o u r s no t ice is give n . Please remember that the charge for your first office visit and physical exam does not include lab or supplement prescription costs.

“I understand and agree that my health insurance is an agreement between my insurance company carrier and myself; and that all services furnished to me are charged directly to me. I further understandthat Sycamore Chiropractic and Nutrition has my permission and will attempt to bill my insurance company, but this will not guarantee that payment by the insurance company is made. In the event that the insurance company does not make payment, I am personally responsible for all charges on my account.

I have read and understand the above statements.

Please Print Name

Signature Date

Many of our patients bring in family members (spouses, parents, etc) to their appointments. This is encouraged, as family support during your treatment is critical to your success. If you would like us to be able to communicate information (lab results, x-rays, etc) about your condition to a family member or designated person in your absence, please list them below.

I give Sycamore Chiropractic and Nutrition my permission to share my medical information with the following people in my absence (please list names below):

1.

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2.