Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset:

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1 C H I R O P R A C T I C O R T H O P E D I C S A N D R E H A B I L I T A T I O N ILJXAi Pain Relief Clinics Please complete all sections. Full Name: Nickname: Gender: M F Age: Race: Date of Birth: I I Family Status: DS DM DW DD Sep P No. Children: Address: City: State: Zip: Home Phone: Ceil: Work Phone: prefer to be contacted at: Home Cell Work SSN#: Emergency Contact: Relationship: Phone: Can we contact you by ? Y e s N o E m a i l : Employer: Occupation: Years on the Job: Employers Address: City: State: Zip: Who referred you to the clinic? Do you have health insurance? NA Yes No Insurance company: ID#: Group#: Are you the primary subscriber? Yes No Who is the primary subscriber? Are you on their plan? NA Yes DNo Name of Primary: ONLY FOR THOSE INVOLVED IN A CAR ACCIDENT: Claim number: Date of birth of primary: insurance Company: Billing Address: City State Zip: Date of injury: Claim Manager's Name: Phone number: Attorney's Name: NA Phone number: ONLY FOR THOSE INVOLVED IN AN ON THE JOB ACCIDENT: Claim number: Self Insured Ye s No Is this your first Doctor visit for this injury: Yes DNo Chiropractic Care approved? Yes DNo Approval Date: Who initiated your claim? Primary Doctor Yes DNo Urgent Care Center? Yes DNo Name of Doctor: Attorney's Name: N A Phone number: Date of Injury: CHIEF COMPLAINT INFORMATION: What is your chief complaint today? (See diagram on page 3) When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset: P L E A S E C O M P L E T E T H E F O L L O W I N G T W O PA G E S! E Indiana Ave Ste 1111 i Spokane Valley, WA Fax:

2 Pain Relief Clinics What activities aggravate your condition? What activities improve your condition? Is your condition getting: Worse Better Staying the same Is your condition interfering with: Work Sleep Daily Routine Other: Is your condition worse during certain times of the day? Yes No If yes, when? Is your condition better during certain times of the day? Yes No If yes, when? Are you currently using any 'home remedies"? Have you ever been to a chiropractor before? Yes No Date of last treatment: List other health care providers you have seen for this condition: What have they recommended and what has been the outcome? Name of DC: Did you have X-rays or MRI or any other imaging performed? Yes No What body part? Which Imaging center performed the testing? Estimated date of most recent Imaging? PAST MEDICAL HISTORY Do you have a primary care physician? Yes No If yes, who? Have you been treated by a physician for any health condition In the past 6 months? Yes No Please describe: Have you ever had any of the following? Surgery Fractures Car Accidents On the job injuries Serious Illness Trauma C a n c e r Stroke H e a r t a t t a c k TIA Describe: Please list your medications: Please list your allergies: PAST FAMILY HISTORY Do you have a family history of: Heart Disease Cancer Stroke Diabetes Arthritis Back or Disc Problems O t h e r D e s c r i b e : SOCIAL HISTORY Exercise None Light Moderate Heavy Number of times per week: Alcohol None Light Moderate Heavy Number of drinks per week: Coffee None Light Moderate Heavy Number of cups per week: Vitamins None Light Moderate Heavy Number of times taken per week: Smoking None Light Moderate Heavy Number of cigarettes per week: Water None Light Moderate Heavy Number of glasses per day: Are there certain activities that you have not been able to do that you would like to be able to return to performing? (Please list) P a t i e n t s S i g n a t u r e : D a t e : V E Indiana Ave Suite 1111 Spokane Valley, WA j Fax:

3 ilja^^ (Ljol^ Pain Relief Clinics C H I R O P R A C T I C O R T H O P E D I C S A N D R E H A B I L I T A T I O N Patient name: Date: DESCRIBE YOUR CHIEF COMPLAINT TODAY: constant comes and goes sharp dull ache burning shooting Symptoms other than above: Mark or circle the area of your symptoms on the drawing and indicate if painful^ numb, tingling or aggravated. C) Q r Q V I S U A L A N A L O G U E S C A L E Please rate your pain regarding your chief complaint No Pain Severe Rain E.Indiana Ave [ Spokane, WA j Fax: wvvw.pearsonweary.com

4 ~ J C H I R O P R A C T I C O R T H O P E D I C S & R E H A B I L I T A T I O N KELLI PEARSON, DC. DABCO DANA WEARY. DC, DABCO J A M I E G O R E. D C J E N M A T S C H. D C I n O r d e r t o u p d a t e t h e i n f o r m a t i o n i n o u r n e w E l e c t r o n i c H e a l t h R e c o r d, p l e a s e c h e c k t h o s e h e a l t h c o n c e r n s t h a t A P P L Y T O Y O U W I T H T H E P E R T I N E N T M O N T H A N D Y E A R I F P O S S I B L E. Condition Now Past Date Condition Now Past Date Headaches Stroke TIA Vertigo Dizziness L o s s o f c o n s c i o u s n e s s Heart Condition High Blood Pressure Double Vision Lumbar Surgery Cervical Surgery Herniated cervical disc H e r n i a t e d l u m b a r d i s c Memory Loss Diabetes Bleeding Disorders Irritable Bowel P l a n t a r f a s c i a M o t o r V e h i c l e A c c i d e n t Head Trauma Indigestion / Heart Burn Leg fracture A r m f r a c t u r e Spine Fracture Cancer C r o h n ' s D i s e a s e Fibromyalgia Nerve disorder Anxiety Depression Osteoarthritis Rheumatoid Arthritis T M J / J a w P a i n Knee pain Shoulder pain Elbow pain Carpal Tunnel Osteoporosis Joint Replacement Other: Taking blood thinners L o s s o f B o w e l C o n t r o l Data entered by: Audited by: Date Entered;

5 Patient Specific Functional and Pain Scale (PSFS) Name: Account Number: Patient Instructions: You must score a total of 3 activities, and ONLY 3 activities that you are having the most difficulty with, or are unable to perform. Please be AS SPECIFIC as possible if you are choosing your own activities. The scoring scale is listed below. 0 = U n a b l e t o = Able to perform perform activity activity at 100% Specific Activity Please Pick Only 3 Scoring Scale 0-10 Date: Date: Date: Date; Example: Sitting for more than 45 minutes 4 Going from sitting to standing Walking up stairs OR down stairs (circle) S t a n d i n a f o r m i n u t e s / h o u r s C c i r c l e ^ S i t t i n a f o r m i n u t e s / h o u r s ( c i r o i e ^ L i f t i n a I b. s o v e r h e a d O R f r o m fl o o r f o i r o i e l D r i v i n a f o r m i n u t e s / h o u r s f c i r r ^ i e ^ T u r n i n a m v n e c k d e f t o r R i o h t i w h i l e d r i v i n n L a v i n a o n m v ( L e f t o r R i o h t ) s i d e a t n i o h t Pain while sleeoina hours C a r r v i n a b a b v / c h l l d f o r m i n u t e s / h o u r s f o i r o l e ^ V a c u u m i n a f o r m i n u t e s / h o u r s f c l r c l e l Getting my pants or shoes on/off (circle) Getting my coat or shirt on/off (circle) Reaching up OR behind your body (circle) Specific Activity: (optlonal) Specific Activity: (optional) Final Score Entered By Doctor