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Welcome to Vitality Family Chiropractic. Please fill this form out to the best of your ability, if there are anysections that do not apply, simply write N/A and move on to the next question.Name: Date of Birth: Age:Address: City: State: Zip:Phone: (H) (W) (C) Email:Occupation: Employer: Marital Status: S M D WSpouse’s Name: Spouse’s Occupation:Emergency Contact - Name: Relationship: Phone:Referred By: Facebook Ad Instagram Google Family/Friend (Name):Number of Children and AgesName:Previous Chiropractic Care?Age: Yes No ReasonName:Age: Yes No ReasonName:Age: Yes No ReasonName:Age: Yes No ReasonLIST YOUR HEALTH CONCERNS BELOWHealth Concerns:List according to severityRate of Severity1 mild10 unbearableWhen didthis episodestart?If you had thecondition before,when?1.2.3.4.5.HAVE YOU EVER SEEN OTHER DOCTORS FOR THESE CONDITIONS?Did theproblem beginwith an injury?Are symptomsconstant orintermittent?YES / NOCHIROPRACTOR? MEDICAL DOCTOR? OTHERWHO AND WHEN?

CIRCLE ALL CONDITIONS YOU HAVE OR HAVE HAD:DIZZINESSDEPRESSIONKIDNEY PROBLEMSLIVER DISEASENERVOUSNESSHEADACHESAUTOIMMUNE DISEASEMID BACK PAINSHOULDER PAINEPILEPSYVERTIGOASTHMAIRRITABLE BOWELCHRONIC FATIGUEDISC PROBLEMEAR INFECTIONSEENTSCIATICARINGING IN THE EARSINFERTILITYNAUSEANUMBNESS/TINGLINGSENSITIVITY TO LIGHTFIBROMYALGIAGASTRIC REFLUXTMJPROSTATE ISSUESSENSITIVITY TO SOUNDCHEST PAINALLERGIESNECK PAINMENSTRUAL DISORDERLOW BACK PAINARM PAINSLEEPING DIFFICULTIESMIGRAINESHEART DISORDERSHIP PAINADD/ADHDOTHER:ANXIETYSTOMACH DISORDERSLEG PAINSJOINT PAINIRRITABILITYBLADDER PROBLEMSKNEE PAINHIGH BLOOD PRESSURELOSS OF MEMORYLOSS OF TASTEHEART BURNCHRONIC SINUSLOSS OF SMELLLOSS OF BALANCESHORTNESS OF BREATHCONSTIPATION/DIARRHEACIRCLE YOUR TOP 3 HEALTH GOALSLESS/NO PAININCREASED PRODUCTIVITYMOTIVATIONLESS/NO MEDICATIONSABILITY TO ENJOY HOBBIESBETTER DIGESTIONPREVENT SURGERYSPEND TIME WITH FAMILYINCREASED STRENGTHINCREASED LONGEVITYINCREASED ENERGYINCREASED MOBILITYLESS ANXIETYBETTER SLEEPWELLNESSCIRCLE ANY CONDITION YOU HAVE NOW/ HAVE HAD (IF NOTHING APPLIES PLEASE WRITE N/A HERE )STROKECANCERHEART DISEASESPINAL SURGERYSEIZURESSPINAL BONE FRACTURESCOLIOSISDIABETESLIST ALL SURGICAL PROCEDURES AND WHENLIST ALL OVER THE COUNTER & PRESCRIPTION MEDICATIONS YOU ARE ON:HAVE YOU BEEN IN AN AUTO ACCIDENT?YES / NO IF YES, WHEN?HAVE YOU HAD PREVIOUS CHIROPRACTIC CARE? YES / NO IF YES, WHEN?REASON CHIROPRACTOR’S NAMEHAVE YOU EVER BEEN KNOCKED UNCONSCIOUS? YES / NOFRACTURED A BONE? YES / NOIF YES, PLEASE DESCRIBEOTHER TRAUMA:HOW WOULD YOU RATE YOUR OVERALL QUALITY OF LIFE (CIRCLE ONE)EXCELLENTGOODAVERAGEFAIRPOOR

WHAT ARE YOU CURRENTLY DOING FOR YOUR HEALTHWHAT DAILY ACTIVITIES ARE BEING RESTRICTED BY YOUR CURRENT HEALTH CONDITION(S)*PLEASE MARK the areas on the Diagram with the following lettersto describe your symptoms:R Radiating B Burning D Dull A Aching N NumbnessS Sharp/ Stabbing T TinglingWhat relieves your symptoms?What makes them feel worse?SOCIAL HISTORY1. SMOKING: YES NO CIGARS PIPE CIGARETTES VAPEHOW OFTEN? DAILY WEEKENDS OCCASIONALLY2. CONSUME ALCOHOL: YES NOHOW OFTEN? DAILY WEEKENDS OCCASIONALLY3. EXERCISE: YES NOHOW OFTEN? 1-2X/WEEK 3-4X/WEEK 5X OR MORE/WEEK OCCASSIONALLYFEMALE HISTORYPlease list your # of Pregnancies: Vaginal Deliveries: Cesarean Surgery: Miscarriages:Deliveries were at Home Birth Center Hospital Other:Have you ever taken or currently taking birth control?Have you ever had infertility issues? Yes No Yes NoDate of last menstrual cycle:--MALE HISTORYHave you ever experienced infertility issues with your spouse? Yes NoErectile dysfunction? Yes NoDate of last prostate exam:Difficulty/pain during urination? Yes No

X-RAY AUTHORIZATIONAS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN ARECORD OF YOUR X-RAYS IN OUR FILES.AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS IN OUR FILES.THE FEE FOR COPYING YOUR X-RAYS ON A DISC IS 15.00. THIS FEE MUST BE PAID IN ADVANCE.DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY.PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS.THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF OZNER FAMILY CHIROPRACTIC DONOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOURATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS.PRINT YOUR NAME HEREDATESIGNATUREYOUR AGEFEMALE PATIENTS ONLY:TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANTAT THE TIME X-RAYS ARE TAKEN AT VITALITY FAMILY CHIROPRACTICSIGNATUREDATEDO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINESex: M F Lat CervicalCMKvp 10-11 78 12-13 14-15 16-17MA 300 Flex/ExtTime MAS 1/24 12.5 1/2015 1/1520 1/1030 2/1540Size 8x10 APOMCMKvpTime 14-15 70 1/10 16-17 2/15 18-19 3/20 20-21 2/10 22-23MA 300Size 8x10MAS20304050 Lower CervicalCMKvpTime 14-15 70 1/10 16-17 2/15 18-19 3/20 20-21 2/10 22-23MA 300Size 8x10MAS20304050OtherViewCM KvpMAS MASizeNotes: Lateral ThoracicCMKvpTime 22-23 80 1/15 24-25 1/10 26-27 2/15 28-29 2/10 30-31 1/4 32-33 3/10 34-35 2/5 36-37 1/2MA 300Size14x17MAS203040507590120150 Lateral LumbarCMKvp Time MAS 26-27 88 2/10 30 28-29 90 1/440 30-31 92 3/10 50 32-33 94 2/570 34-35 96 1/290 36-37 3/5120 38-39 4/5160 40-41 1200 42-43 1 1/2 2MA 200Size 14x17CA Initials: A-P ThoracicCMKvp Time 16-17 75 1/20 18-19 1/15 20-21 1/10 22-23 2/15 24-25 2/10 26-27 1/4 28-29 3/10 30-31 2/5MA 300Size14x17 A-P LumbarCMKvp 20-21 76 22-23 78 24-25 80 26-27 28-29 30-31 32-33 34-35 36-37 38-39 40-41 42-43MA 300Time 1/15 1/10 2/15 2/10 1/4 3/10 2/5 1/2 3/5 4/5 1 1 1/2 2Size 0

Terms of AcceptanceIn order to provide for the most effective healing environment, most effective application of chiropractic procedures, and thestrongest possible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarationsthat will facilitate the goal of optimum health through chiropractic.To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offeredthrough this clinic:A. Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is aseparate and distinct science, art and practice. It is not the practice of medicine.B. Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functionsthrough the adjustment of spinal subluxation(s). Subluxations are deviations from normal spinal structures andconfigurations that interfere with normal nerve processes.C. The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specificdirectional thrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments.This is a safe, effective procedure applied over one million times each day doctors of chiropractic in the United Statesalone.D. A thorough chiropractic examination and evaluation is part of the standard chiropractic procedure. The goal of thisprocess is to identify any spinal health problems and chiropractic needs. If during this process, any condition or questionoutside the scope of chiropractic is identified, you will receive a prompt referral to an appropriate provider or specialist,according to the initial indications of the need.E. Chiropractic does not seek to replace or compete with your medical, dental or other type(s) of health professionals. Theyretain responsibility for care and management of medical conditions. We do not offer advice regarding treatmentprescribed by others.F. Your compliance with care plans, home and self-care, etc., is essential to maximum healing and optimal health thoughchiropracticG. We invite you to speak frankly to the doctor on any matter related to your care at this facility, its nature, duration, or cost,in what we work to maintain as a supporting, open environment.By my signature below, I have read and fully understand the above statements.All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my satisfaction. Itherefore accept chiropractic care on this basis.(Signature)(Date)Notice of Privacy Practices AcknowledgementI understand that I have certain rights of privacy regarding my protected health information, under the Health InsurancePortability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involvedin that treatment directly and indirectly.2. Obtain payment from third-party payers.3. Conduct normal healthcare operations, such as quality assessments and physicians certifications.I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the usesand disclosures of my health information. I also understand that I may request, in writing, that you restrict how my privateinformation is used to disclosed to carry out treatment, payment, or healthcare operation. I also understand you are notrequired to agree to my requested restrictions, but if you agree, then you are bound to abide by such restrictions.(Signature)(Date)

INFORMED CONSENT FOR CHIROPRACTIC CARECHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOMELEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITHCHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CAREINCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RARESTCOMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TOONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILLBE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND INPARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, ORIF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASONTO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILLBE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THEEXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, ASREPORTED FOLLOWING MY ASSESSMENT.PRINT PRACTICE MEMBER’S NAME HEREPRACTICE MEMBER’S SIGNATURE OR GUARDIAN SIGNATUREDATEIF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOWWRITTEN CONSENT FOR A CHILDNAME OF PRACTICE MEMBER WHO IS A MINOR/CHILDI AUTHORIZE DR. KATHERYNE CASTRO AND ANY AND ALL VITALITY FAMILY CHIROPRACTIC STAFF TO PERFORMDIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORMCHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MYMINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILLIMMEDIATELY NOTIFY VITALITY FAMILY CHIROPRACTIC.DATEGUARDIAN SIGNATURE AND RELATIONSHIP TO MINOR / CHILDWITNESS SIGNATURE (OFFICE STAFF)DATE

FAMILY HEALTH HISTORYTHIS FORM IS TO ASSIST THE DOCTORS BY PROVIDING PAST HEALTH HISTORY INFORMATIONFOR THEIR REVIEW.DATEPLEASE PRINT YOUR NAME HERECONDITIONARM PAINARTHRITISASTHMAADD/ADHDALLERGIESBACK TROUBLEBED WETTINGCANCERCARPAL TUNNELDECEASEDDIABETESDIGESTIVE PROBLEMSDISC PROBLEMSEAR INFECTIONSFIBROMYALGIAHEADACHESHEART DISEASEHIGH BLOOD PRESSUREHIP PAINLEG PAINMENSTRUAL DISORDERMIGRAINESNECK PAINSCOLIOSISSHOULDER PAINSINUS TROUBLETMJSPOUSESONDAUGHTERMOTHERFATHER

Authorization FormPatient Name:Address: City: State:Phone Number: - - Email:THE PATIENT ABOVE AUTHORIZES VITALITY FAMILY CHIROPRACTIC, LLC TO USE AND/ORDISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING:SPECIFIC AUTHORIZATIONSYes / No I give Vitality Family Chiropractic, LLC permission to leave messages regardingappointments, finances, and other office concerns via phone call, voicemail, text or email. Vitality FamilyChiropractic, LLC may also leave messages or discuss my care with the following family member orother:Yes / No I give Vitality Family Chiropractic, LLC permission to provide care for me in an open roomwhere other patients are also being cared for. I am aware that other person(s) in the office may overhear some ofmy protected health information during my care. Should I need to speak with the Doctor at any time in private,the Doctor will provide a room for these conversations.Yes / No I give Vitality Family Chiropractic, LLC permission to use my name and/or picture on officepicture boards, testimonials, thank you boards, referral boards and social media sites.Yes / No I give Vitality Family Chiropractic, LLC permission to use and disclose to other HealthcarePractitioners, Health Insurance Companies and attorneys my protected health information and in accordancewith the directives listed above.RIGHT TO REVOKE AUTHORIZATIONSYou have the right to revoke this authorization, in writing, at any time. You may revoke this authorization bymailing or hand delivering a written notice to Vitality Family Chiropractic, LLC. The written notice mustcontain the following information: Your name and date of birth A clear statement of your intent to revoke this authorization The date of your request Your signatureThe revocation will be effective on the date Vitality Family Chiropractic, LLC receives it. You have a right torefuse to sign this authorization. If you refuse to sign this authorization, Vitality Family Chiropractic will notrefuse to provide care.Print Patient NameDateSignature of Patient or Representative or Legal Guardian

that will facilitate the goal of optimum health through chiropractic. To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offered through this clinic: A. Chiropractic is a very specific science, authorized by law to address spinal